In hospital medicine, emergency procedures refer to a set of immediate actions that may be necessary to stabilize or resuscitate patients with impending or established cardiorespiratory arrest or other major organ failure. Such actions may include cardiopulmonary resuscitation using advanced cardiac life support (ACLS) protocols and advanced airway management via endotracheal intubation. In addition, patients may require short-term advanced respiratory support such as mechanical ventilation until their transition to a higher level of care (for example, to an intensive care unit) or until their recovery from a short-term critical illness. Hospitalists care for patients admitted with critical illnesses, or who may become critically ill during the course of their hospitalization, and thus need to perform and supervise such emergency procedures. Hospitalists should lead efforts that ensure the delivery of timely, effective, and standardized responses to such inpatient emergencies. 

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 normal anatomy of the upper airway, thorax, heart, and lungs.

• Describe the clinical findings or disease processes that require cardiopulmonary resuscitation and advanced life support.

• Describe clinical and electrocardiographic findings that affect cardiopulmonary arrest outcome.

• List indicated laboratory and other diagnostic testing during cardiopulmonary distress or arrest and immediately following successful resuscitation.

• Distinguish between current basic life support (BLS) and ACLS protocols, including selection of interventions appropriate to the clinical situation.

• Describe the equipment needed to manage the airway, identify cardiac rhythms, and perform defibrillation.

• Describe cardiac rhythms and clinical situations that require immediate defibrillation.

• Describe the uses of and mechanisms of action of medications used during ACLS implementation.

• Explain the indications for procedural interventions that may be used during the course of resuscitation.

• Define return of spontaneous circulation.

• Describe postresuscitation care protocols.

• Recognize the indications for emergent specialty consultation when available, which may include otolaryngology, surgery, or critical care medicine.

 SKILLS

 Hospitalists should be able to:

• Promptly identify acute cardiopulmonary distress or arrest and call for assistance.

• Assess the patient and the clinical situation in a timely manner and attempt to identify the cause and other complicating factors.

• Elicit additional pertinent information from available sources such as the patient’s family, other healthcare providers, and the medical record when available.

• Interpret cardiac rhythms and other diagnostic indicators.

• Perform, coordinate, and lead prompt and effective resuscitation in a manner consistent with current ACLS protocols.

• Facilitate interactions between healthcare professionals regarding the roles that each will perform during the resuscitation effort.

• Synthesize diagnostic information to deliver medications and/or defibrillation and perform procedures required during resuscitation efforts.

• Maintain safety of all team members by taking necessary precautions and using appropriate protective wear.

• Evaluate the quality of ongoing resuscitation efforts and implement changes as necessary.

• Discontinue resuscitation efforts when interventions have been unsuccessful and continued efforts are deemed medically futile.

• Arrange for appropriate care transitions following successful resuscitation.

• Review the resuscitation documentation for accuracy immediately following the event.

• Communicate with families to explain the procedures performed as well as outcomes and next steps in management. 

ATTITUDES 

Hospitalists should be able to:

• Review and respect the advance directives and resuscitation choices of patients and/or their surrogates.

• Rapidly respond to emergencies without distraction.

• Appreciate the value of spiritual support services during and following resuscitation efforts. 

KNOWLEDGE

Hospitalists should be able to:

• Describe the normal anatomy of the upper airway.

• Describe clinical findings or disease processes that may require securing an airway.

• Describe the indications, contraindications, benefits, and risks of endotracheal intubation.

• Describe the necessary equipment and medications required for routine and complicated intubations.

• Describe the process of endotracheal intubation from laryngoscope assembly to assessment of tube placement.

• Differentiate among alternatives to endotracheal intubation.

• Recognize indications for appropriate specialty consultation for difficult or unsuccessful intubations or when clinician experience level precludes intubation trial.

SKILLS

Hospitalists should be able to:

• Identify patients who may benefit from endotracheal intubation.

• Assess patients for degree of procedural complexity and complication risk.

• Perform prompt and safe endotracheal intubation using techniques selective to the patient’s anatomy and condition.

• Determine and place the endotracheal tube at an appropriate depth in the airway.

• Confirm endotracheal tube placement by approved methods and make adjustments as necessary.

• Use an alternative suitable airway control for patients with difficult or unsuccessful intubations.

• Maintain safety of all team members by taking necessary precautions and using appropriate protective wear.

• Evaluate for procedural complications and adopt necessary measures.

• Communicate with families to explain the procedures performed as well as outcomes and next steps in management.

ATTITUDES 

Hospitalists should be able to:

• Review and respect the advance directives and resuscitation choices of patients and/or their surrogates.

• Rapidly respond to emergencies without distraction.

• Demonstrate awareness of and ability to address periprocedural emotional and physical discomfort.

KNOWLEDGE

Hospitalists should be able to:

•  Describe the normal anatomy of the respiratory system.

• Describe disease processes that lead to respiratory failure.

• Describe the indications, benefits, and risks of mechanical ventilation.

• Describe indications and contraindications for noninvasive ventilation in selected patients.

• Explain the role of arterial blood gas analysis in the management of ventilated patients.

• Explain the basic components and workings of a ventilator.

• Describe available modes of ventilation and process of selection of suitable ventilator settings.

• List causes of ventilator alarms.

• Recognize the indications for specialty consultation, which may include critical care medicine.

 SKILLS

 Hospitalists should be able to:

• Use nursing and respiratory therapy reports, physical examination findings, and ventilator data to identify complications due to mechanical ventilation.

• Provide adequate sedation, comfort management, and paralysis when indicated for patients requiring mechanical ventilation.

• Select and adjust the ventilator mode and settings on the basis of the disease process, patient factors, ventilator data, and laboratory findings.

• Institute indicated interventions when complications of mechanical ventilation are encountered.

• Order and interpret laboratory and imaging studies on the basis of changes in the patient’s clinical status.

• Evaluate and treat underlying conditions leading to respiratory failure.

• Implement evidence-based interventions known to reduce risk of ventilator-associated complications.

• Communicate with families to explain the procedures performed as well as outcomes and next steps in management.

 ATTITUDES 

Hospitalists should be able to:

• Review and respect the advance directives and resuscitation choices of patients and/or their surrogates.

• Rapidly respond to emergencies without distraction.

• Appreciate the value of spiritual support services during and following resuscitation efforts. 

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

• Lead, coordinate, and/or participate in multidisciplinary teams, which may include critical care nurses, respiratory therapists, and critical care and emergency physicians, to establish ongoing training to ensure high-quality performance of emergency procedures.

• Lead, coordinate, and/or participate in multidisciplinary efforts to review antecedent events to identify changes in clinical status that, if promptly identified and acted upon, may have prevented the emergency intervention.

• Facilitate appropriate organization and consolidation of equipment in multiple identifiable and accessible locations in the hospital for the optimal performance of emergency procedures.

• Lead, coordinate, and/or participate in evaluation of resuscitation and mechanical ventilation outcomes and identify and implement improvement initiatives.

In hospital medicine, emergency procedures refer to a set of immediate actions that may be necessary to stabilize or resuscitate patients with impending or established cardiorespiratory arrest or other major organ failure. Such actions may include cardiopulmonary resuscitation using advanced cardiac life support (ACLS) protocols and advanced airway management via endotracheal intubation. In addition, patients may require short-term advanced respiratory support such as mechanical ventilation until their transition to a higher level of care (for example, to an intensive care unit) or until their recovery from a short-term critical illness. Hospitalists care for patients admitted with critical illnesses, or who may become critically ill during the course of their hospitalization, and thus need to perform and supervise such emergency procedures. Hospitalists should lead efforts that ensure the delivery of timely, effective, and standardized responses to such inpatient emergencies. 

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 normal anatomy of the upper airway, thorax, heart, and lungs.

• Describe the clinical findings or disease processes that require cardiopulmonary resuscitation and advanced life support.

• Describe clinical and electrocardiographic findings that affect cardiopulmonary arrest outcome.

• List indicated laboratory and other diagnostic testing during cardiopulmonary distress or arrest and immediately following successful resuscitation.

• Distinguish between current basic life support (BLS) and ACLS protocols, including selection of interventions appropriate to the clinical situation.

• Describe the equipment needed to manage the airway, identify cardiac rhythms, and perform defibrillation.

• Describe cardiac rhythms and clinical situations that require immediate defibrillation.

• Describe the uses of and mechanisms of action of medications used during ACLS implementation.

• Explain the indications for procedural interventions that may be used during the course of resuscitation.

• Define return of spontaneous circulation.

• Describe postresuscitation care protocols.

• Recognize the indications for emergent specialty consultation when available, which may include otolaryngology, surgery, or critical care medicine.

 SKILLS

 Hospitalists should be able to:

• Promptly identify acute cardiopulmonary distress or arrest and call for assistance.

• Assess the patient and the clinical situation in a timely manner and attempt to identify the cause and other complicating factors.

• Elicit additional pertinent information from available sources such as the patient’s family, other healthcare providers, and the medical record when available.

• Interpret cardiac rhythms and other diagnostic indicators.

• Perform, coordinate, and lead prompt and effective resuscitation in a manner consistent with current ACLS protocols.

• Facilitate interactions between healthcare professionals regarding the roles that each will perform during the resuscitation effort.

• Synthesize diagnostic information to deliver medications and/or defibrillation and perform procedures required during resuscitation efforts.

• Maintain safety of all team members by taking necessary precautions and using appropriate protective wear.

• Evaluate the quality of ongoing resuscitation efforts and implement changes as necessary.

• Discontinue resuscitation efforts when interventions have been unsuccessful and continued efforts are deemed medically futile.

• Arrange for appropriate care transitions following successful resuscitation.

• Review the resuscitation documentation for accuracy immediately following the event.

• Communicate with families to explain the procedures performed as well as outcomes and next steps in management. 

ATTITUDES 

Hospitalists should be able to:

• Review and respect the advance directives and resuscitation choices of patients and/or their surrogates.

• Rapidly respond to emergencies without distraction.

• Appreciate the value of spiritual support services during and following resuscitation efforts. 

KNOWLEDGE

Hospitalists should be able to:

• Describe the normal anatomy of the upper airway.

• Describe clinical findings or disease processes that may require securing an airway.

• Describe the indications, contraindications, benefits, and risks of endotracheal intubation.

• Describe the necessary equipment and medications required for routine and complicated intubations.

• Describe the process of endotracheal intubation from laryngoscope assembly to assessment of tube placement.

• Differentiate among alternatives to endotracheal intubation.

• Recognize indications for appropriate specialty consultation for difficult or unsuccessful intubations or when clinician experience level precludes intubation trial.

SKILLS

Hospitalists should be able to:

• Identify patients who may benefit from endotracheal intubation.

• Assess patients for degree of procedural complexity and complication risk.

• Perform prompt and safe endotracheal intubation using techniques selective to the patient’s anatomy and condition.

• Determine and place the endotracheal tube at an appropriate depth in the airway.

• Confirm endotracheal tube placement by approved methods and make adjustments as necessary.

• Use an alternative suitable airway control for patients with difficult or unsuccessful intubations.

• Maintain safety of all team members by taking necessary precautions and using appropriate protective wear.

• Evaluate for procedural complications and adopt necessary measures.

• Communicate with families to explain the procedures performed as well as outcomes and next steps in management.

ATTITUDES 

Hospitalists should be able to:

• Review and respect the advance directives and resuscitation choices of patients and/or their surrogates.

• Rapidly respond to emergencies without distraction.

• Demonstrate awareness of and ability to address periprocedural emotional and physical discomfort.

KNOWLEDGE

Hospitalists should be able to:

•  Describe the normal anatomy of the respiratory system.

• Describe disease processes that lead to respiratory failure.

• Describe the indications, benefits, and risks of mechanical ventilation.

• Describe indications and contraindications for noninvasive ventilation in selected patients.

• Explain the role of arterial blood gas analysis in the management of ventilated patients.

• Explain the basic components and workings of a ventilator.

• Describe available modes of ventilation and process of selection of suitable ventilator settings.

• List causes of ventilator alarms.

• Recognize the indications for specialty consultation, which may include critical care medicine.

 SKILLS

 Hospitalists should be able to:

• Use nursing and respiratory therapy reports, physical examination findings, and ventilator data to identify complications due to mechanical ventilation.

• Provide adequate sedation, comfort management, and paralysis when indicated for patients requiring mechanical ventilation.

• Select and adjust the ventilator mode and settings on the basis of the disease process, patient factors, ventilator data, and laboratory findings.

• Institute indicated interventions when complications of mechanical ventilation are encountered.

• Order and interpret laboratory and imaging studies on the basis of changes in the patient’s clinical status.

• Evaluate and treat underlying conditions leading to respiratory failure.

• Implement evidence-based interventions known to reduce risk of ventilator-associated complications.

• Communicate with families to explain the procedures performed as well as outcomes and next steps in management.

 ATTITUDES 

Hospitalists should be able to:

• Review and respect the advance directives and resuscitation choices of patients and/or their surrogates.

• Rapidly respond to emergencies without distraction.

• Appreciate the value of spiritual support services during and following resuscitation efforts. 

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

• Lead, coordinate, and/or participate in multidisciplinary teams, which may include critical care nurses, respiratory therapists, and critical care and emergency physicians, to establish ongoing training to ensure high-quality performance of emergency procedures.

• Lead, coordinate, and/or participate in multidisciplinary efforts to review antecedent events to identify changes in clinical status that, if promptly identified and acted upon, may have prevented the emergency intervention.

• Facilitate appropriate organization and consolidation of equipment in multiple identifiable and accessible locations in the hospital for the optimal performance of emergency procedures.

• Lead, coordinate, and/or participate in evaluation of resuscitation and mechanical ventilation outcomes and identify and implement improvement initiatives.

In hospital medicine, emergency procedures refer to a set of immediate actions that may be necessary to stabilize or resuscitate patients with impending or established cardiorespiratory arrest or other major organ failure. Such actions may include cardiopulmonary resuscitation using advanced cardiac life support (ACLS) protocols and advanced airway management via endotracheal intubation. In addition, patients may require short-term advanced respiratory support such as mechanical ventilation until their transition to a higher level of care (for example, to an intensive care unit) or until their recovery from a short-term critical illness. Hospitalists care for patients admitted with critical illnesses, or who may become critically ill during the course of their hospitalization, and thus need to perform and supervise such emergency procedures. Hospitalists should lead efforts that ensure the delivery of timely, effective, and standardized responses to such inpatient emergencies. 

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 normal anatomy of the upper airway, thorax, heart, and lungs.

• Describe the clinical findings or disease processes that require cardiopulmonary resuscitation and advanced life support.

• Describe clinical and electrocardiographic findings that affect cardiopulmonary arrest outcome.

• List indicated laboratory and other diagnostic testing during cardiopulmonary distress or arrest and immediately following successful resuscitation.

• Distinguish between current basic life support (BLS) and ACLS protocols, including selection of interventions appropriate to the clinical situation.

• Describe the equipment needed to manage the airway, identify cardiac rhythms, and perform defibrillation.

• Describe cardiac rhythms and clinical situations that require immediate defibrillation.

• Describe the uses of and mechanisms of action of medications used during ACLS implementation.

• Explain the indications for procedural interventions that may be used during the course of resuscitation.

• Define return of spontaneous circulation.

• Describe postresuscitation care protocols.

• Recognize the indications for emergent specialty consultation when available, which may include otolaryngology, surgery, or critical care medicine.

 SKILLS

 Hospitalists should be able to:

• Promptly identify acute cardiopulmonary distress or arrest and call for assistance.

• Assess the patient and the clinical situation in a timely manner and attempt to identify the cause and other complicating factors.

• Elicit additional pertinent information from available sources such as the patient’s family, other healthcare providers, and the medical record when available.

• Interpret cardiac rhythms and other diagnostic indicators.

• Perform, coordinate, and lead prompt and effective resuscitation in a manner consistent with current ACLS protocols.

• Facilitate interactions between healthcare professionals regarding the roles that each will perform during the resuscitation effort.

• Synthesize diagnostic information to deliver medications and/or defibrillation and perform procedures required during resuscitation efforts.

• Maintain safety of all team members by taking necessary precautions and using appropriate protective wear.

• Evaluate the quality of ongoing resuscitation efforts and implement changes as necessary.

• Discontinue resuscitation efforts when interventions have been unsuccessful and continued efforts are deemed medically futile.

• Arrange for appropriate care transitions following successful resuscitation.

• Review the resuscitation documentation for accuracy immediately following the event.

• Communicate with families to explain the procedures performed as well as outcomes and next steps in management. 

ATTITUDES 

Hospitalists should be able to:

• Review and respect the advance directives and resuscitation choices of patients and/or their surrogates.

• Rapidly respond to emergencies without distraction.

• Appreciate the value of spiritual support services during and following resuscitation efforts. 

KNOWLEDGE

Hospitalists should be able to:

• Describe the normal anatomy of the upper airway.

• Describe clinical findings or disease processes that may require securing an airway.

• Describe the indications, contraindications, benefits, and risks of endotracheal intubation.

• Describe the necessary equipment and medications required for routine and complicated intubations.

• Describe the process of endotracheal intubation from laryngoscope assembly to assessment of tube placement.

• Differentiate among alternatives to endotracheal intubation.

• Recognize indications for appropriate specialty consultation for difficult or unsuccessful intubations or when clinician experience level precludes intubation trial.

SKILLS

Hospitalists should be able to:

• Identify patients who may benefit from endotracheal intubation.

• Assess patients for degree of procedural complexity and complication risk.

• Perform prompt and safe endotracheal intubation using techniques selective to the patient’s anatomy and condition.

• Determine and place the endotracheal tube at an appropriate depth in the airway.

• Confirm endotracheal tube placement by approved methods and make adjustments as necessary.

• Use an alternative suitable airway control for patients with difficult or unsuccessful intubations.

• Maintain safety of all team members by taking necessary precautions and using appropriate protective wear.

• Evaluate for procedural complications and adopt necessary measures.

• Communicate with families to explain the procedures performed as well as outcomes and next steps in management.

ATTITUDES 

Hospitalists should be able to:

• Review and respect the advance directives and resuscitation choices of patients and/or their surrogates.

• Rapidly respond to emergencies without distraction.

• Demonstrate awareness of and ability to address periprocedural emotional and physical discomfort.

KNOWLEDGE

Hospitalists should be able to:

•  Describe the normal anatomy of the respiratory system.

• Describe disease processes that lead to respiratory failure.

• Describe the indications, benefits, and risks of mechanical ventilation.

• Describe indications and contraindications for noninvasive ventilation in selected patients.

• Explain the role of arterial blood gas analysis in the management of ventilated patients.

• Explain the basic components and workings of a ventilator.

• Describe available modes of ventilation and process of selection of suitable ventilator settings.

• List causes of ventilator alarms.

• Recognize the indications for specialty consultation, which may include critical care medicine.

 SKILLS

 Hospitalists should be able to:

• Use nursing and respiratory therapy reports, physical examination findings, and ventilator data to identify complications due to mechanical ventilation.

• Provide adequate sedation, comfort management, and paralysis when indicated for patients requiring mechanical ventilation.

• Select and adjust the ventilator mode and settings on the basis of the disease process, patient factors, ventilator data, and laboratory findings.

• Institute indicated interventions when complications of mechanical ventilation are encountered.

• Order and interpret laboratory and imaging studies on the basis of changes in the patient’s clinical status.

• Evaluate and treat underlying conditions leading to respiratory failure.

• Implement evidence-based interventions known to reduce risk of ventilator-associated complications.

• Communicate with families to explain the procedures performed as well as outcomes and next steps in management.

 ATTITUDES 

Hospitalists should be able to:

• Review and respect the advance directives and resuscitation choices of patients and/or their surrogates.

• Rapidly respond to emergencies without distraction.

• Appreciate the value of spiritual support services during and following resuscitation efforts. 

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

• Lead, coordinate, and/or participate in multidisciplinary teams, which may include critical care nurses, respiratory therapists, and critical care and emergency physicians, to establish ongoing training to ensure high-quality performance of emergency procedures.

• Lead, coordinate, and/or participate in multidisciplinary efforts to review antecedent events to identify changes in clinical status that, if promptly identified and acted upon, may have prevented the emergency intervention.

• Facilitate appropriate organization and consolidation of equipment in multiple identifiable and accessible locations in the hospital for the optimal performance of emergency procedures.

• Lead, coordinate, and/or participate in evaluation of resuscitation and mechanical ventilation outcomes and identify and implement improvement initiatives.

Lumbar puncture is a procedure during which a needle is inserted into the subarachnoid space to obtain cerebrospinal fluid (CSF) for laboratory analysis to assess for acute or chronic central nervous system (CNS) disease processes. It is one of the more commonly performed bedside procedures in hospitalized patients and is often considered the cornerstone for the diagnosis of acute bacterial, fungal, and viral CNS infections and subarachnoid hemorrhage.¹ Hospitalists may suspect the presence of such conditions during their patient assessment and should use clinical expertise and evidence-based decision-making to determine whether a lumbar puncture is required in the diagnosis and management of the patient’s illness. 

Hospitalists should be able to:

• Describe the anatomy of the spinal column and the spinal cord and identify anatomic landmarks to guide proper entry point for lumbar puncture.

• Explain the indications and contraindications for lumbar puncture including potential risks, benefits, and complications.

• List the indications for CNS imaging before lumbar puncture.

• Explain the appropriate diagnostic tests necessary to characterize CSF on the basis of the clinical presentation.

• Recognize the indications for specialty consultation, which may include interventional radiology, infectious disease, or neurology.

Hospitalists should be able to:

• Assess patients for increased risk of complications and use appropriate preventive measures.

• Select the necessary equipment to perform a lumbar puncture at the bedside.

• Demonstrate the optimal patient positioning to safely perform a lumbar puncture.

• Demonstrate proficiency in performance of lumbar puncture.

• Perform a time-out before the procedure.

• Use appropriate sterile technique and necessary precautions throughout the procedure to minimize the risk of complications for patients and providers.

• Order and interpret the results of CSF analyses to determine an appropriate management plan.

• Anticipate and manage complications of lumbar puncture after the procedure, which may include bleeding, headache, or infection.

• Obtain informed consent and effectively communicate with patients and families to explain the procedure, its expected diagnostic or therapeutic benefits, and potential complications. 

Hospitalists should be able to:

• Demonstrate awareness of and ability to address periprocedural emotional and physical discomfort. 

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

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

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

• Lead, coordinate, and/or participate in patient safety and quality improvement programs to monitor hospitalists’ performance and/or supervision of procedural competence.

• Lead, coordinate, and/or participate in patient safety programs designed to coordinate care transition and the handoff of pending test results at the time of hospital discharge.

• Collaborate with emergency physicians to develop protocols for rapid identification and evaluation of patients with suspected CNS infections, bleeding, and other life-threatening conditions.

Lumbar puncture is a procedure during which a needle is inserted into the subarachnoid space to obtain cerebrospinal fluid (CSF) for laboratory analysis to assess for acute or chronic central nervous system (CNS) disease processes. It is one of the more commonly performed bedside procedures in hospitalized patients and is often considered the cornerstone for the diagnosis of acute bacterial, fungal, and viral CNS infections and subarachnoid hemorrhage.¹ Hospitalists may suspect the presence of such conditions during their patient assessment and should use clinical expertise and evidence-based decision-making to determine whether a lumbar puncture is required in the diagnosis and management of the patient’s illness. 

Hospitalists should be able to:

• Describe the anatomy of the spinal column and the spinal cord and identify anatomic landmarks to guide proper entry point for lumbar puncture.

• Explain the indications and contraindications for lumbar puncture including potential risks, benefits, and complications.

• List the indications for CNS imaging before lumbar puncture.

• Explain the appropriate diagnostic tests necessary to characterize CSF on the basis of the clinical presentation.

• Recognize the indications for specialty consultation, which may include interventional radiology, infectious disease, or neurology.

Hospitalists should be able to:

• Assess patients for increased risk of complications and use appropriate preventive measures.

• Select the necessary equipment to perform a lumbar puncture at the bedside.

• Demonstrate the optimal patient positioning to safely perform a lumbar puncture.

• Demonstrate proficiency in performance of lumbar puncture.

• Perform a time-out before the procedure.

• Use appropriate sterile technique and necessary precautions throughout the procedure to minimize the risk of complications for patients and providers.

• Order and interpret the results of CSF analyses to determine an appropriate management plan.

• Anticipate and manage complications of lumbar puncture after the procedure, which may include bleeding, headache, or infection.

• Obtain informed consent and effectively communicate with patients and families to explain the procedure, its expected diagnostic or therapeutic benefits, and potential complications. 

Hospitalists should be able to:

• Demonstrate awareness of and ability to address periprocedural emotional and physical discomfort. 

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

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

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

• Lead, coordinate, and/or participate in patient safety and quality improvement programs to monitor hospitalists’ performance and/or supervision of procedural competence.

• Lead, coordinate, and/or participate in patient safety programs designed to coordinate care transition and the handoff of pending test results at the time of hospital discharge.

• Collaborate with emergency physicians to develop protocols for rapid identification and evaluation of patients with suspected CNS infections, bleeding, and other life-threatening conditions.

Lumbar puncture is a procedure during which a needle is inserted into the subarachnoid space to obtain cerebrospinal fluid (CSF) for laboratory analysis to assess for acute or chronic central nervous system (CNS) disease processes. It is one of the more commonly performed bedside procedures in hospitalized patients and is often considered the cornerstone for the diagnosis of acute bacterial, fungal, and viral CNS infections and subarachnoid hemorrhage.¹ Hospitalists may suspect the presence of such conditions during their patient assessment and should use clinical expertise and evidence-based decision-making to determine whether a lumbar puncture is required in the diagnosis and management of the patient’s illness. 

Hospitalists should be able to:

• Describe the anatomy of the spinal column and the spinal cord and identify anatomic landmarks to guide proper entry point for lumbar puncture.

• Explain the indications and contraindications for lumbar puncture including potential risks, benefits, and complications.

• List the indications for CNS imaging before lumbar puncture.

• Explain the appropriate diagnostic tests necessary to characterize CSF on the basis of the clinical presentation.

• Recognize the indications for specialty consultation, which may include interventional radiology, infectious disease, or neurology.

Hospitalists should be able to:

• Assess patients for increased risk of complications and use appropriate preventive measures.

• Select the necessary equipment to perform a lumbar puncture at the bedside.

• Demonstrate the optimal patient positioning to safely perform a lumbar puncture.

• Demonstrate proficiency in performance of lumbar puncture.

• Perform a time-out before the procedure.

• Use appropriate sterile technique and necessary precautions throughout the procedure to minimize the risk of complications for patients and providers.

• Order and interpret the results of CSF analyses to determine an appropriate management plan.

• Anticipate and manage complications of lumbar puncture after the procedure, which may include bleeding, headache, or infection.

• Obtain informed consent and effectively communicate with patients and families to explain the procedure, its expected diagnostic or therapeutic benefits, and potential complications. 

Hospitalists should be able to:

• Demonstrate awareness of and ability to address periprocedural emotional and physical discomfort. 

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

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

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

• Lead, coordinate, and/or participate in patient safety and quality improvement programs to monitor hospitalists’ performance and/or supervision of procedural competence.

• Lead, coordinate, and/or participate in patient safety programs designed to coordinate care transition and the handoff of pending test results at the time of hospital discharge.

• Collaborate with emergency physicians to develop protocols for rapid identification and evaluation of patients with suspected CNS infections, bleeding, and other life-threatening conditions.

Paracentesis, the aspiration of fluid from the peritoneal cavity, is frequently performed in the diagnosis and management of patients with ascites from various causes. Currently, paracentesis may be underused in hospitalized patients with ascites, and evidence suggests that this procedure may be associated with reduced short-term mortality.¹ Hospitalists may identify ascites during the history and physical examination and should use clinical expertise and evidence-based decision-making to determine whether paracentesis is indicated in the diagnosis or management of the patient’s illness. 

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 normal anatomy of the abdomen and pelvis.

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

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

• Describe the accuracy of physical examination maneuvers in the evaluation of ascites.

• Differentiate among the indications for a diagnostic and therapeutic paracentesis.

• Describe the indications for the use of additional modalities such as ultrasonography to assess and/or guide paracentesis.

• Explain the appropriate diagnostic tests to accurately characterize ascitic fluid.

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

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

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

Hospitalists should be able to:

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

• Perform a physical examination to evaluate for signs of the primary condition responsible for the development of ascites.

• Assess patients for increased risk of complications and use appropriate preventive measures.

• Demonstrate the optimal patient positioning during paracentesis.

• Select the necessary equipment to perform a paracentesis safely at the bedside.

• Perform a time-out before the procedure.

• Use appropriate sterile technique and necessary precautions throughout the procedure to minimize the risk of complications for patients and providers.

• Order and interpret the results of ascitic fluid analyses to determine an appropriate management plan.

• Anticipate and manage complications of paracentesis after the procedure, which may include bleeding, leakage, or infection.

• Obtain informed consent and effectively communicate with patients and families to explain the procedure, its expected diagnostic or therapeutic benefits, and potential complications. 

Hospitalists should be able to:

• Demonstrate awareness of and ability to address periprocedural emotional and physical discomfort. 

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

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

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

• Lead, coordinate, and/or participate in patient safety and quality improvement programs to monitor hospitalists’ performance and/or supervision of procedural competence.

• Lead, coordinate, and/or participate in patient safety programs designed to coordinate care transition and the handoff of pending test results at the time of hospital discharge.

Paracentesis, the aspiration of fluid from the peritoneal cavity, is frequently performed in the diagnosis and management of patients with ascites from various causes. Currently, paracentesis may be underused in hospitalized patients with ascites, and evidence suggests that this procedure may be associated with reduced short-term mortality.¹ Hospitalists may identify ascites during the history and physical examination and should use clinical expertise and evidence-based decision-making to determine whether paracentesis is indicated in the diagnosis or management of the patient’s illness. 

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 normal anatomy of the abdomen and pelvis.

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

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

• Describe the accuracy of physical examination maneuvers in the evaluation of ascites.

• Differentiate among the indications for a diagnostic and therapeutic paracentesis.

• Describe the indications for the use of additional modalities such as ultrasonography to assess and/or guide paracentesis.

• Explain the appropriate diagnostic tests to accurately characterize ascitic fluid.

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

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

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

Hospitalists should be able to:

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

• Perform a physical examination to evaluate for signs of the primary condition responsible for the development of ascites.

• Assess patients for increased risk of complications and use appropriate preventive measures.

• Demonstrate the optimal patient positioning during paracentesis.

• Select the necessary equipment to perform a paracentesis safely at the bedside.

• Perform a time-out before the procedure.

• Use appropriate sterile technique and necessary precautions throughout the procedure to minimize the risk of complications for patients and providers.

• Order and interpret the results of ascitic fluid analyses to determine an appropriate management plan.

• Anticipate and manage complications of paracentesis after the procedure, which may include bleeding, leakage, or infection.

• Obtain informed consent and effectively communicate with patients and families to explain the procedure, its expected diagnostic or therapeutic benefits, and potential complications. 

Hospitalists should be able to:

• Demonstrate awareness of and ability to address periprocedural emotional and physical discomfort. 

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

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

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

• Lead, coordinate, and/or participate in patient safety and quality improvement programs to monitor hospitalists’ performance and/or supervision of procedural competence.

• Lead, coordinate, and/or participate in patient safety programs designed to coordinate care transition and the handoff of pending test results at the time of hospital discharge.

Paracentesis, the aspiration of fluid from the peritoneal cavity, is frequently performed in the diagnosis and management of patients with ascites from various causes. Currently, paracentesis may be underused in hospitalized patients with ascites, and evidence suggests that this procedure may be associated with reduced short-term mortality.¹ Hospitalists may identify ascites during the history and physical examination and should use clinical expertise and evidence-based decision-making to determine whether paracentesis is indicated in the diagnosis or management of the patient’s illness. 

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 normal anatomy of the abdomen and pelvis.

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

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

• Describe the accuracy of physical examination maneuvers in the evaluation of ascites.

• Differentiate among the indications for a diagnostic and therapeutic paracentesis.

• Describe the indications for the use of additional modalities such as ultrasonography to assess and/or guide paracentesis.

• Explain the appropriate diagnostic tests to accurately characterize ascitic fluid.

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

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

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

Hospitalists should be able to:

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

• Perform a physical examination to evaluate for signs of the primary condition responsible for the development of ascites.

• Assess patients for increased risk of complications and use appropriate preventive measures.

• Demonstrate the optimal patient positioning during paracentesis.

• Select the necessary equipment to perform a paracentesis safely at the bedside.

• Perform a time-out before the procedure.

• Use appropriate sterile technique and necessary precautions throughout the procedure to minimize the risk of complications for patients and providers.

• Order and interpret the results of ascitic fluid analyses to determine an appropriate management plan.

• Anticipate and manage complications of paracentesis after the procedure, which may include bleeding, leakage, or infection.

• Obtain informed consent and effectively communicate with patients and families to explain the procedure, its expected diagnostic or therapeutic benefits, and potential complications. 

Hospitalists should be able to:

• Demonstrate awareness of and ability to address periprocedural emotional and physical discomfort. 

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

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

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

• Lead, coordinate, and/or participate in patient safety and quality improvement programs to monitor hospitalists’ performance and/or supervision of procedural competence.

• Lead, coordinate, and/or participate in patient safety programs designed to coordinate care transition and the handoff of pending test results at the time of hospital discharge.

Thoracentesis is a procedure involving the withdrawal of fluid from the pleural cavity to determine the etiology of or to treat the effects of a pleural effusion. It is a frequently performed bedside procedure for both diagnostic and therapeutic purposes. The most common clinically important complication is pneumothorax. With the advent of ultrasound guidance, the rate of pneumothorax after thoracentesis in nonventilated patients is less than 2%.^1-3 Hospitalists may identify pleural effusions during the history and physical examination and should use clinical expertise and evidence-based decision-making to determine whether a thoracentesis is required in the diagnosis and management of the patient’s illness. 

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 normal anatomy of the chest wall, thorax, and lung.

• Define and differentiate the disease processes that may lead to the development of pleural effusion.

• Define and differentiate transudative from exudative pleural effusions.

• Explain indications and contraindications of thoracentesis and its potential risks and complications.

• Describe the proper use of ultrasonography in guiding thoracentesis.

• Explain the appropriate diagnostic tests to accurately characterize pleural fluid and identify the underlying disease process.

• Recognize indications for specialty consultations, which may include interventional radiology, pulmonary medicine, infectious disease, or cardiothoracic surgery.

Hospitalists should be able to:

• Elicit a thorough and relevant medical history to identify potential disease processes and risk factors for the development of pleural effusions.

• Perform a chest examination including specific maneuvers to assess for the presence and size of the pleural effusion.

• Demonstrate the optimal patient position for safely performing a thoracentesis.

• Perform a time-out before the procedure.

• Perform a competent diagnostic and/or therapeutic thoracentesis with standard use of ultrasound guidance.

• Select the necessary equipment to perform a thoracentesis safely at the bedside.

• Use appropriate sterile technique and necessary precautions throughout the procedure to minimize the risk of complications for patients and providers.

• Order and interpret the results of pleural fluid analyses to determine an appropriate management plan.

• Anticipate and manage complications of thoracentesis after the procedure, which may include pneumothorax, bleeding, leakage, or infection.

• Obtain informed consent and effectively communicate with patients and families to explain the procedure, its expected diagnostic or therapeutic benefits, and potential complications. 

Hospitalists should be able to:

• Demonstrate awareness of and ability to address periprocedural emotional and physical discomfort. 

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

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

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

• Lead, coordinate, and/or participate in patient safety and quality improvement programs to monitor hospitalists’ performance and/or supervision of procedural competence.

• Lead, coordinate, and/or participate in patient safety programs designed to coordinate care transition and the handoff of pending test results at the time of hospital discharge.

Thoracentesis is a procedure involving the withdrawal of fluid from the pleural cavity to determine the etiology of or to treat the effects of a pleural effusion. It is a frequently performed bedside procedure for both diagnostic and therapeutic purposes. The most common clinically important complication is pneumothorax. With the advent of ultrasound guidance, the rate of pneumothorax after thoracentesis in nonventilated patients is less than 2%.^1-3 Hospitalists may identify pleural effusions during the history and physical examination and should use clinical expertise and evidence-based decision-making to determine whether a thoracentesis is required in the diagnosis and management of the patient’s illness. 

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 normal anatomy of the chest wall, thorax, and lung.

• Define and differentiate the disease processes that may lead to the development of pleural effusion.

• Define and differentiate transudative from exudative pleural effusions.

• Explain indications and contraindications of thoracentesis and its potential risks and complications.

• Describe the proper use of ultrasonography in guiding thoracentesis.

• Explain the appropriate diagnostic tests to accurately characterize pleural fluid and identify the underlying disease process.

• Recognize indications for specialty consultations, which may include interventional radiology, pulmonary medicine, infectious disease, or cardiothoracic surgery.

Hospitalists should be able to:

• Elicit a thorough and relevant medical history to identify potential disease processes and risk factors for the development of pleural effusions.

• Perform a chest examination including specific maneuvers to assess for the presence and size of the pleural effusion.

• Demonstrate the optimal patient position for safely performing a thoracentesis.

• Perform a time-out before the procedure.

• Perform a competent diagnostic and/or therapeutic thoracentesis with standard use of ultrasound guidance.

• Select the necessary equipment to perform a thoracentesis safely at the bedside.

• Use appropriate sterile technique and necessary precautions throughout the procedure to minimize the risk of complications for patients and providers.

• Order and interpret the results of pleural fluid analyses to determine an appropriate management plan.

• Anticipate and manage complications of thoracentesis after the procedure, which may include pneumothorax, bleeding, leakage, or infection.

• Obtain informed consent and effectively communicate with patients and families to explain the procedure, its expected diagnostic or therapeutic benefits, and potential complications. 

Hospitalists should be able to:

• Demonstrate awareness of and ability to address periprocedural emotional and physical discomfort. 

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

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

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

• Lead, coordinate, and/or participate in patient safety and quality improvement programs to monitor hospitalists’ performance and/or supervision of procedural competence.

• Lead, coordinate, and/or participate in patient safety programs designed to coordinate care transition and the handoff of pending test results at the time of hospital discharge.

Thoracentesis is a procedure involving the withdrawal of fluid from the pleural cavity to determine the etiology of or to treat the effects of a pleural effusion. It is a frequently performed bedside procedure for both diagnostic and therapeutic purposes. The most common clinically important complication is pneumothorax. With the advent of ultrasound guidance, the rate of pneumothorax after thoracentesis in nonventilated patients is less than 2%.^1-3 Hospitalists may identify pleural effusions during the history and physical examination and should use clinical expertise and evidence-based decision-making to determine whether a thoracentesis is required in the diagnosis and management of the patient’s illness. 

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 normal anatomy of the chest wall, thorax, and lung.

• Define and differentiate the disease processes that may lead to the development of pleural effusion.

• Define and differentiate transudative from exudative pleural effusions.

• Explain indications and contraindications of thoracentesis and its potential risks and complications.

• Describe the proper use of ultrasonography in guiding thoracentesis.

• Explain the appropriate diagnostic tests to accurately characterize pleural fluid and identify the underlying disease process.

• Recognize indications for specialty consultations, which may include interventional radiology, pulmonary medicine, infectious disease, or cardiothoracic surgery.

Hospitalists should be able to:

• Elicit a thorough and relevant medical history to identify potential disease processes and risk factors for the development of pleural effusions.

• Perform a chest examination including specific maneuvers to assess for the presence and size of the pleural effusion.

• Demonstrate the optimal patient position for safely performing a thoracentesis.

• Perform a time-out before the procedure.

• Perform a competent diagnostic and/or therapeutic thoracentesis with standard use of ultrasound guidance.

• Select the necessary equipment to perform a thoracentesis safely at the bedside.

• Use appropriate sterile technique and necessary precautions throughout the procedure to minimize the risk of complications for patients and providers.

• Order and interpret the results of pleural fluid analyses to determine an appropriate management plan.

• Anticipate and manage complications of thoracentesis after the procedure, which may include pneumothorax, bleeding, leakage, or infection.

• Obtain informed consent and effectively communicate with patients and families to explain the procedure, its expected diagnostic or therapeutic benefits, and potential complications. 

Hospitalists should be able to:

• Demonstrate awareness of and ability to address periprocedural emotional and physical discomfort. 

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

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

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

• Lead, coordinate, and/or participate in patient safety and quality improvement programs to monitor hospitalists’ performance and/or supervision of procedural competence.

• Lead, coordinate, and/or participate in patient safety programs designed to coordinate care transition and the handoff of pending test results at the time of hospital discharge.

Persons aged 65 years or older represent only 14% of the US population, yet account for more than 34% of hospital discharges.^1-4 The population aged 65 years and older is growing at a faster rate than the total population, and the number of persons in this group is projected to double by 2050.^1-4 Because of decreased physiologic reserves, changes in pharmacokinetics of medications, and decreased functional capacity of organ systems, the hospitalized older patient is at risk for many poor outcomes. Such outcomes include cognitive and functional decline, prolonged length of stay, higher rates of readmission, and increased risk of death. Because of clinically significant functional decline experienced during hospitalization, more than 28% of older patients are discharged to nursing care facilities rather than home.¹ These outcomes have profound medical, psychosocial, and economic effects on individual patients, families, and society. In addition to disease-based management, care of the older inpatient must be approached within a specific psychosocial and functional context. Hospitalists must engage in a collaborative, interprofessional approach to optimize care provided to older patients, beginning at the time of hospital admission and continuing through all care transitions. Hospitalists should lead initiatives that improve the care of older patients. 

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 common complications related to hospitalization in older patients.

• Describe physiologic changes with aging that create increased vulnerability to adverse events during hospitalization.

• Describe patient-specific, environmental, and iatrogenic risk factors for complications in hospitalized older patients.

• Describe the high-risk medication classes that lead to most unplanned emergency department visits and emergency hospitalizations in older patients.

• Describe the medical, psychosocial, and economic impact of hospitalization on older patients and their families.

• Describe interventions shown to improve outcomes in hospitalized older patients.

• Describe postacute care options that can enable older patients to regain functional capacity.

• Identify all forms of delirium.

• Describe the impact of delirium on patients’ functional and cognitive recovery from the acute illness.

• Recognize that agitation is a symptom of a disease, often delirium, and that the underlying cause must be addressed to ensure adequate care.

• Appreciate the risks and complications associated with restraint use.

• Summarize the costs and implications of the intersection between healthcare finance and obtaining resources to compensate for functional deficits in older patients.

Hospitalists should be able to:

• Elicit a thorough medical history and perform a physical examination to identify patient-specific risk factors for complications during hospitalization.

• Perform a focused cognitive and functional assessment of older patients.

• Formulate multidisciplinary care plans for the prevention of delirium, falls, and functional decline.

• Investigate and appropriately address underlying contributors to delirium.

• Provide nonpharmacologic alternatives (for example, behavioral plans) for the management of agitation and insomnia while minimizing exposure to potentially inappropriate medications.

• Avoid prescribing, whenever possible, medications associated with low benefit and/or increased risk of adverse drug reactions in older patients.

• Assess the complications and potential adverse effects associated with polypharmacy and work to avoid unnecessary medication exposure.

• Incorporate unique characteristics of older patients into the development and communication of therapeutic plans.

• Perform a social assessment of the patient’s living conditions and support systems and tailor the healthcare plan to each patient’s unique needs.

• Formulate and communicate safe multidisciplinary plans for care transitions for older patients with complex discharge needs.

• Connect elderly patients with social services early in the hospital course to provide institutional support, which may include referral for insurance and medication benefits, transportation, mental health services, and substance abuse services.

• Communicate effectively with primary care physicians and other postacute care providers to promote safe, coordinated care transitions.

• Educate patients and families about individual measures and community resources that can reduce potential complications after discharge.

• Recognize signs of potential elder abuse and use designated mechanisms to report suspected abuse or neglect.

• Lead, coordinate, and/or participate in multidisciplinary patient safety initiatives to reduce common complications experienced by older patients during hospitalization.

• Lead, coordinate, and/or participate in hospital initiatives to improve care transitions and reduce postacute care complications in older patients. 

Hospitalists should be able to:

• Promote a team approach to the care of the hospitalized older patient, which may include physicians, geriatricians, psychiatrists, nurses, pharmacists, social workers, and rehabilitation services.

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

Persons aged 65 years or older represent only 14% of the US population, yet account for more than 34% of hospital discharges.^1-4 The population aged 65 years and older is growing at a faster rate than the total population, and the number of persons in this group is projected to double by 2050.^1-4 Because of decreased physiologic reserves, changes in pharmacokinetics of medications, and decreased functional capacity of organ systems, the hospitalized older patient is at risk for many poor outcomes. Such outcomes include cognitive and functional decline, prolonged length of stay, higher rates of readmission, and increased risk of death. Because of clinically significant functional decline experienced during hospitalization, more than 28% of older patients are discharged to nursing care facilities rather than home.¹ These outcomes have profound medical, psychosocial, and economic effects on individual patients, families, and society. In addition to disease-based management, care of the older inpatient must be approached within a specific psychosocial and functional context. Hospitalists must engage in a collaborative, interprofessional approach to optimize care provided to older patients, beginning at the time of hospital admission and continuing through all care transitions. Hospitalists should lead initiatives that improve the care of older patients. 

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 common complications related to hospitalization in older patients.

• Describe physiologic changes with aging that create increased vulnerability to adverse events during hospitalization.

• Describe patient-specific, environmental, and iatrogenic risk factors for complications in hospitalized older patients.

• Describe the high-risk medication classes that lead to most unplanned emergency department visits and emergency hospitalizations in older patients.

• Describe the medical, psychosocial, and economic impact of hospitalization on older patients and their families.

• Describe interventions shown to improve outcomes in hospitalized older patients.

• Describe postacute care options that can enable older patients to regain functional capacity.

• Identify all forms of delirium.

• Describe the impact of delirium on patients’ functional and cognitive recovery from the acute illness.

• Recognize that agitation is a symptom of a disease, often delirium, and that the underlying cause must be addressed to ensure adequate care.

• Appreciate the risks and complications associated with restraint use.

• Summarize the costs and implications of the intersection between healthcare finance and obtaining resources to compensate for functional deficits in older patients.

Hospitalists should be able to:

• Elicit a thorough medical history and perform a physical examination to identify patient-specific risk factors for complications during hospitalization.

• Perform a focused cognitive and functional assessment of older patients.

• Formulate multidisciplinary care plans for the prevention of delirium, falls, and functional decline.

• Investigate and appropriately address underlying contributors to delirium.

• Provide nonpharmacologic alternatives (for example, behavioral plans) for the management of agitation and insomnia while minimizing exposure to potentially inappropriate medications.

• Avoid prescribing, whenever possible, medications associated with low benefit and/or increased risk of adverse drug reactions in older patients.

• Assess the complications and potential adverse effects associated with polypharmacy and work to avoid unnecessary medication exposure.

• Incorporate unique characteristics of older patients into the development and communication of therapeutic plans.

• Perform a social assessment of the patient’s living conditions and support systems and tailor the healthcare plan to each patient’s unique needs.

• Formulate and communicate safe multidisciplinary plans for care transitions for older patients with complex discharge needs.

• Connect elderly patients with social services early in the hospital course to provide institutional support, which may include referral for insurance and medication benefits, transportation, mental health services, and substance abuse services.

• Communicate effectively with primary care physicians and other postacute care providers to promote safe, coordinated care transitions.

• Educate patients and families about individual measures and community resources that can reduce potential complications after discharge.

• Recognize signs of potential elder abuse and use designated mechanisms to report suspected abuse or neglect.

• Lead, coordinate, and/or participate in multidisciplinary patient safety initiatives to reduce common complications experienced by older patients during hospitalization.

• Lead, coordinate, and/or participate in hospital initiatives to improve care transitions and reduce postacute care complications in older patients. 

Hospitalists should be able to:

• Promote a team approach to the care of the hospitalized older patient, which may include physicians, geriatricians, psychiatrists, nurses, pharmacists, social workers, and rehabilitation services.

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

Persons aged 65 years or older represent only 14% of the US population, yet account for more than 34% of hospital discharges.^1-4 The population aged 65 years and older is growing at a faster rate than the total population, and the number of persons in this group is projected to double by 2050.^1-4 Because of decreased physiologic reserves, changes in pharmacokinetics of medications, and decreased functional capacity of organ systems, the hospitalized older patient is at risk for many poor outcomes. Such outcomes include cognitive and functional decline, prolonged length of stay, higher rates of readmission, and increased risk of death. Because of clinically significant functional decline experienced during hospitalization, more than 28% of older patients are discharged to nursing care facilities rather than home.¹ These outcomes have profound medical, psychosocial, and economic effects on individual patients, families, and society. In addition to disease-based management, care of the older inpatient must be approached within a specific psychosocial and functional context. Hospitalists must engage in a collaborative, interprofessional approach to optimize care provided to older patients, beginning at the time of hospital admission and continuing through all care transitions. Hospitalists should lead initiatives that improve the care of older patients. 

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 common complications related to hospitalization in older patients.

• Describe physiologic changes with aging that create increased vulnerability to adverse events during hospitalization.

• Describe patient-specific, environmental, and iatrogenic risk factors for complications in hospitalized older patients.

• Describe the high-risk medication classes that lead to most unplanned emergency department visits and emergency hospitalizations in older patients.

• Describe the medical, psychosocial, and economic impact of hospitalization on older patients and their families.

• Describe interventions shown to improve outcomes in hospitalized older patients.

• Describe postacute care options that can enable older patients to regain functional capacity.

• Identify all forms of delirium.

• Describe the impact of delirium on patients’ functional and cognitive recovery from the acute illness.

• Recognize that agitation is a symptom of a disease, often delirium, and that the underlying cause must be addressed to ensure adequate care.

• Appreciate the risks and complications associated with restraint use.

• Summarize the costs and implications of the intersection between healthcare finance and obtaining resources to compensate for functional deficits in older patients.

Hospitalists should be able to:

• Elicit a thorough medical history and perform a physical examination to identify patient-specific risk factors for complications during hospitalization.

• Perform a focused cognitive and functional assessment of older patients.

• Formulate multidisciplinary care plans for the prevention of delirium, falls, and functional decline.

• Investigate and appropriately address underlying contributors to delirium.

• Provide nonpharmacologic alternatives (for example, behavioral plans) for the management of agitation and insomnia while minimizing exposure to potentially inappropriate medications.

• Avoid prescribing, whenever possible, medications associated with low benefit and/or increased risk of adverse drug reactions in older patients.

• Assess the complications and potential adverse effects associated with polypharmacy and work to avoid unnecessary medication exposure.

• Incorporate unique characteristics of older patients into the development and communication of therapeutic plans.

• Perform a social assessment of the patient’s living conditions and support systems and tailor the healthcare plan to each patient’s unique needs.

• Formulate and communicate safe multidisciplinary plans for care transitions for older patients with complex discharge needs.

• Connect elderly patients with social services early in the hospital course to provide institutional support, which may include referral for insurance and medication benefits, transportation, mental health services, and substance abuse services.

• Communicate effectively with primary care physicians and other postacute care providers to promote safe, coordinated care transitions.

• Educate patients and families about individual measures and community resources that can reduce potential complications after discharge.

• Recognize signs of potential elder abuse and use designated mechanisms to report suspected abuse or neglect.

• Lead, coordinate, and/or participate in multidisciplinary patient safety initiatives to reduce common complications experienced by older patients during hospitalization.

• Lead, coordinate, and/or participate in hospital initiatives to improve care transitions and reduce postacute care complications in older patients. 

Hospitalists should be able to:

• Promote a team approach to the care of the hospitalized older patient, which may include physicians, geriatricians, psychiatrists, nurses, pharmacists, social workers, and rehabilitation services.

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

Health disparities are differences in health outcomes that reflect social inequalities among groups. Vulnerable populations are defined as groups that are at increased risk of experiencing a disparity in medical care on the basis of characteristics such as age, sex, race, ethnicity, sexual orientation, spirituality, disability status, or socioeconomic or insurance status. When compared with patients from nonvulnerable populations, patients from vulnerable populations are prone to lower rates of health literacy, higher rates of preventable hospitalizations, higher rates of hospital patient safety events, and higher death rates from typically low-mortality diseases.¹ More than 30% of direct medical care expenditures for African American, Asian, and Hispanic patients are excess costs due to health disparities.² Hospitalists may have an important role in influencing the health status, healthcare access, and healthcare delivery to vulnerable populations given higher rates of hospital use and reduced access to outpatient care. In fact, hospitalists often serve as initial points of contact for the healthcare of these groups. Core competencies in communication, advocacy, and comprehension of the healthcare needs of vulnerable populations may influence healthcare expenditures, morbidity, and mortality. Hospitalists have the opportunity to lead initiatives that promote equity of healthcare provision. 

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 key factors leading to disparities in health status among specific vulnerable populations.

• Explain disease processes that disproportionately affect vulnerable populations.

• Describe key factors leading to disparities in the quality of care provided to vulnerable groups.

• List services in local healthcare systems designed to ameliorate barriers to care provision.

• Name local and institutional resources available to patients needing financial assistance.

• Identify key elements of discharge planning for uninsured, underinsured, and disabled patients.

Hospitalists should be able to:

• Elicit a thorough and relevant medical history and perform a physical examination to detect illnesses for which vulnerable populations may have increased risk.

• Elicit a social history to assess patient habits, identify patients at risk for breaks in transitions of care, and clarify patient values regarding treatment options.

• Facilitate communication between vulnerable patient groups and consultants.

• Select appropriate educational resources to inform vulnerable patients with low health literacy using terminology commensurate with the patient’s level of understanding.

• Provide education and systems interventions to minimize medication errors in patients with low health literacy.

• Secure medical interpreters to assist with interviewing, physical examination, and medical decision-making.

• Tailor the therapeutic plan, which includes the discharge plan and outpatient resources.

• Connect vulnerable patients with social services early in the hospital course to provide institutional support, which may include referral for insurance and drug benefits, transportation, mental health services, and substance abuse services.

• Target vulnerable groups for indicated vaccinations and preventive care services or referrals.

• Identify vulnerable patients whose outpatient environment might benefit from additional community resources.

• Coordinate adequate transitions of care from the inpatient to outpatient setting, including communication with outpatient providers. 

Hospitalists should be able to:

• Communicate openly to facilitate trust in patient-physician interactions.

• Actively involve patients and families in the design of care plans.

• Provide leadership to foster attitudes and systems improvements that promote quality healthcare provision to vulnerable populations.

Health disparities are differences in health outcomes that reflect social inequalities among groups. Vulnerable populations are defined as groups that are at increased risk of experiencing a disparity in medical care on the basis of characteristics such as age, sex, race, ethnicity, sexual orientation, spirituality, disability status, or socioeconomic or insurance status. When compared with patients from nonvulnerable populations, patients from vulnerable populations are prone to lower rates of health literacy, higher rates of preventable hospitalizations, higher rates of hospital patient safety events, and higher death rates from typically low-mortality diseases.¹ More than 30% of direct medical care expenditures for African American, Asian, and Hispanic patients are excess costs due to health disparities.² Hospitalists may have an important role in influencing the health status, healthcare access, and healthcare delivery to vulnerable populations given higher rates of hospital use and reduced access to outpatient care. In fact, hospitalists often serve as initial points of contact for the healthcare of these groups. Core competencies in communication, advocacy, and comprehension of the healthcare needs of vulnerable populations may influence healthcare expenditures, morbidity, and mortality. Hospitalists have the opportunity to lead initiatives that promote equity of healthcare provision. 

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 key factors leading to disparities in health status among specific vulnerable populations.

• Explain disease processes that disproportionately affect vulnerable populations.

• Describe key factors leading to disparities in the quality of care provided to vulnerable groups.

• List services in local healthcare systems designed to ameliorate barriers to care provision.

• Name local and institutional resources available to patients needing financial assistance.

• Identify key elements of discharge planning for uninsured, underinsured, and disabled patients.

Hospitalists should be able to:

• Elicit a thorough and relevant medical history and perform a physical examination to detect illnesses for which vulnerable populations may have increased risk.

• Elicit a social history to assess patient habits, identify patients at risk for breaks in transitions of care, and clarify patient values regarding treatment options.

• Facilitate communication between vulnerable patient groups and consultants.

• Select appropriate educational resources to inform vulnerable patients with low health literacy using terminology commensurate with the patient’s level of understanding.

• Provide education and systems interventions to minimize medication errors in patients with low health literacy.

• Secure medical interpreters to assist with interviewing, physical examination, and medical decision-making.

• Tailor the therapeutic plan, which includes the discharge plan and outpatient resources.

• Connect vulnerable patients with social services early in the hospital course to provide institutional support, which may include referral for insurance and drug benefits, transportation, mental health services, and substance abuse services.

• Target vulnerable groups for indicated vaccinations and preventive care services or referrals.

• Identify vulnerable patients whose outpatient environment might benefit from additional community resources.

• Coordinate adequate transitions of care from the inpatient to outpatient setting, including communication with outpatient providers. 

Hospitalists should be able to:

• Communicate openly to facilitate trust in patient-physician interactions.

• Actively involve patients and families in the design of care plans.

• Provide leadership to foster attitudes and systems improvements that promote quality healthcare provision to vulnerable populations.

Health disparities are differences in health outcomes that reflect social inequalities among groups. Vulnerable populations are defined as groups that are at increased risk of experiencing a disparity in medical care on the basis of characteristics such as age, sex, race, ethnicity, sexual orientation, spirituality, disability status, or socioeconomic or insurance status. When compared with patients from nonvulnerable populations, patients from vulnerable populations are prone to lower rates of health literacy, higher rates of preventable hospitalizations, higher rates of hospital patient safety events, and higher death rates from typically low-mortality diseases.¹ More than 30% of direct medical care expenditures for African American, Asian, and Hispanic patients are excess costs due to health disparities.² Hospitalists may have an important role in influencing the health status, healthcare access, and healthcare delivery to vulnerable populations given higher rates of hospital use and reduced access to outpatient care. In fact, hospitalists often serve as initial points of contact for the healthcare of these groups. Core competencies in communication, advocacy, and comprehension of the healthcare needs of vulnerable populations may influence healthcare expenditures, morbidity, and mortality. Hospitalists have the opportunity to lead initiatives that promote equity of healthcare provision. 

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Hospitalists should be able to:

• Explain key factors leading to disparities in health status among specific vulnerable populations.

• Explain disease processes that disproportionately affect vulnerable populations.

• Describe key factors leading to disparities in the quality of care provided to vulnerable groups.

• List services in local healthcare systems designed to ameliorate barriers to care provision.

• Name local and institutional resources available to patients needing financial assistance.

• Identify key elements of discharge planning for uninsured, underinsured, and disabled patients.

Hospitalists should be able to:

• Elicit a thorough and relevant medical history and perform a physical examination to detect illnesses for which vulnerable populations may have increased risk.

• Elicit a social history to assess patient habits, identify patients at risk for breaks in transitions of care, and clarify patient values regarding treatment options.

• Facilitate communication between vulnerable patient groups and consultants.

• Select appropriate educational resources to inform vulnerable patients with low health literacy using terminology commensurate with the patient’s level of understanding.

• Provide education and systems interventions to minimize medication errors in patients with low health literacy.

• Secure medical interpreters to assist with interviewing, physical examination, and medical decision-making.

• Tailor the therapeutic plan, which includes the discharge plan and outpatient resources.

• Connect vulnerable patients with social services early in the hospital course to provide institutional support, which may include referral for insurance and drug benefits, transportation, mental health services, and substance abuse services.

• Target vulnerable groups for indicated vaccinations and preventive care services or referrals.

• Identify vulnerable patients whose outpatient environment might benefit from additional community resources.

• Coordinate adequate transitions of care from the inpatient to outpatient setting, including communication with outpatient providers. 

Hospitalists should be able to:

• Communicate openly to facilitate trust in patient-physician interactions.

• Actively involve patients and families in the design of care plans.

• Provide leadership to foster attitudes and systems improvements that promote quality healthcare provision to vulnerable populations.

Communication refers to the transfer of information among individuals, groups, or organizations. Hospitalists communicate in multiple modalities with patients, families, other healthcare providers, and administrators. Patient-centered care requires that physicians and members of multidisciplinary teams effectively inform, educate, reassure, and empower patients and families to participate in the creation of a care plan. An estimated 80% of serious medical errors are due to failures in communication.¹ Preventable adverse events are a leading cause of death and injury in the United States.² Therefore, effective communication is central to the role of the hospitalist to promote efficient, safe, and high-quality care and to minimize discontinuity of care. Hospitalists can lead initiatives to improve communication among team members, patients, families, primary care physicians, and receiving physicians within the hospital and at extended-care facilities beginning at admission and through all care transitions. 

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Hospitalists should be able to:

• Describe key elements in a message.

• Describe the advantages and disadvantages of various communication modalities such as verbal, written, nonverbal, and listening approaches.

• Describe techniques of providing and eliciting feedback.

• Distinguish between formative and summative feedback.

• Define the role of effective communication in risk management.

Hospitalists should be able to:

• Communicate medical information in accordance with the recipient’s preferred style with language understandable to patients, family members, and other care providers.

• Effectively use various communication methods, including nonverbal communication, in patient and family interactions.

• Identify and incorporate the use of appropriate multimedia resources to improve effective communication of the message.

• Use a medical interpreter when communicating with patients and families speaking a different language.

• Lead, coordinate, and/or participate in hospital initiatives to ensure adequate interpreter services and cross-cultural sensitivity.

• Identify potentially problematic family and team dynamics and explore their effects on the patient.

• Use advance care planning skills to identify the patient’s choice of a surrogate decision maker.

• Ensure that input from surrogate decision makers accurately reflects the patient’s interests, with a minimum of personal bias.

• Facilitate family meetings when necessary, collaborating with nurses and other team members to identify goals for the meeting, summarize conclusions reached, and use support staff as needed.

• Identify and provide a suitable and comfortable setting for family meetings.

• Counsel patients and families objectively when considering various treatment options.

• Communicate with nursing staff and consultants on a regular basis to convey critical information. 

Hospitalists should be able to:

• Appreciate the positive impact that subtle changes in body language, such as sitting and appropriate touching, have on patient and family perceptions of an interaction.

• Demonstrate empathy for patient and family concerns.

• Demonstrate cultural sensitivity in all interactions with patients and families.

• Recognize the importance of allowing patients and families to have questions answered in a straightforward and timely manner.

• Discuss the patient’s illness realistically without negating hope.

• Appreciate the importance of active and reflective listening.

• Acknowledge and remain comfortable with uncertainty in issues of prognosis.

• Remain available to the patient and family for follow-up questions through all care transitions.

Communication refers to the transfer of information among individuals, groups, or organizations. Hospitalists communicate in multiple modalities with patients, families, other healthcare providers, and administrators. Patient-centered care requires that physicians and members of multidisciplinary teams effectively inform, educate, reassure, and empower patients and families to participate in the creation of a care plan. An estimated 80% of serious medical errors are due to failures in communication.¹ Preventable adverse events are a leading cause of death and injury in the United States.² Therefore, effective communication is central to the role of the hospitalist to promote efficient, safe, and high-quality care and to minimize discontinuity of care. Hospitalists can lead initiatives to improve communication among team members, patients, families, primary care physicians, and receiving physicians within the hospital and at extended-care facilities beginning at admission and through all care transitions. 

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 key elements in a message.

• Describe the advantages and disadvantages of various communication modalities such as verbal, written, nonverbal, and listening approaches.

• Describe techniques of providing and eliciting feedback.

• Distinguish between formative and summative feedback.

• Define the role of effective communication in risk management.

Hospitalists should be able to:

• Communicate medical information in accordance with the recipient’s preferred style with language understandable to patients, family members, and other care providers.

• Effectively use various communication methods, including nonverbal communication, in patient and family interactions.

• Identify and incorporate the use of appropriate multimedia resources to improve effective communication of the message.

• Use a medical interpreter when communicating with patients and families speaking a different language.

• Lead, coordinate, and/or participate in hospital initiatives to ensure adequate interpreter services and cross-cultural sensitivity.

• Identify potentially problematic family and team dynamics and explore their effects on the patient.

• Use advance care planning skills to identify the patient’s choice of a surrogate decision maker.

• Ensure that input from surrogate decision makers accurately reflects the patient’s interests, with a minimum of personal bias.

• Facilitate family meetings when necessary, collaborating with nurses and other team members to identify goals for the meeting, summarize conclusions reached, and use support staff as needed.

• Identify and provide a suitable and comfortable setting for family meetings.

• Counsel patients and families objectively when considering various treatment options.

• Communicate with nursing staff and consultants on a regular basis to convey critical information. 

Hospitalists should be able to:

• Appreciate the positive impact that subtle changes in body language, such as sitting and appropriate touching, have on patient and family perceptions of an interaction.

• Demonstrate empathy for patient and family concerns.

• Demonstrate cultural sensitivity in all interactions with patients and families.

• Recognize the importance of allowing patients and families to have questions answered in a straightforward and timely manner.

• Discuss the patient’s illness realistically without negating hope.

• Appreciate the importance of active and reflective listening.

• Acknowledge and remain comfortable with uncertainty in issues of prognosis.

• Remain available to the patient and family for follow-up questions through all care transitions.

Communication refers to the transfer of information among individuals, groups, or organizations. Hospitalists communicate in multiple modalities with patients, families, other healthcare providers, and administrators. Patient-centered care requires that physicians and members of multidisciplinary teams effectively inform, educate, reassure, and empower patients and families to participate in the creation of a care plan. An estimated 80% of serious medical errors are due to failures in communication.¹ Preventable adverse events are a leading cause of death and injury in the United States.² Therefore, effective communication is central to the role of the hospitalist to promote efficient, safe, and high-quality care and to minimize discontinuity of care. Hospitalists can lead initiatives to improve communication among team members, patients, families, primary care physicians, and receiving physicians within the hospital and at extended-care facilities beginning at admission and through all care transitions. 

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 key elements in a message.

• Describe the advantages and disadvantages of various communication modalities such as verbal, written, nonverbal, and listening approaches.

• Describe techniques of providing and eliciting feedback.

• Distinguish between formative and summative feedback.

• Define the role of effective communication in risk management.

Hospitalists should be able to:

• Communicate medical information in accordance with the recipient’s preferred style with language understandable to patients, family members, and other care providers.

• Effectively use various communication methods, including nonverbal communication, in patient and family interactions.

• Identify and incorporate the use of appropriate multimedia resources to improve effective communication of the message.

• Use a medical interpreter when communicating with patients and families speaking a different language.

• Lead, coordinate, and/or participate in hospital initiatives to ensure adequate interpreter services and cross-cultural sensitivity.

• Identify potentially problematic family and team dynamics and explore their effects on the patient.

• Use advance care planning skills to identify the patient’s choice of a surrogate decision maker.

• Ensure that input from surrogate decision makers accurately reflects the patient’s interests, with a minimum of personal bias.

• Facilitate family meetings when necessary, collaborating with nurses and other team members to identify goals for the meeting, summarize conclusions reached, and use support staff as needed.

• Identify and provide a suitable and comfortable setting for family meetings.

• Counsel patients and families objectively when considering various treatment options.

• Communicate with nursing staff and consultants on a regular basis to convey critical information. 

Hospitalists should be able to:

• Appreciate the positive impact that subtle changes in body language, such as sitting and appropriate touching, have on patient and family perceptions of an interaction.

• Demonstrate empathy for patient and family concerns.

• Demonstrate cultural sensitivity in all interactions with patients and families.

• Recognize the importance of allowing patients and families to have questions answered in a straightforward and timely manner.

• Discuss the patient’s illness realistically without negating hope.

• Appreciate the importance of active and reflective listening.

• Acknowledge and remain comfortable with uncertainty in issues of prognosis.

• Remain available to the patient and family for follow-up questions through all care transitions.

Diagnostic decision-making refers to the process of evaluating a patient complaint to develop a differential diagnosis, design a diagnostic evaluation, and arrive at a final diagnosis. Hospitalists frequently care for acutely ill patients with undifferentiated symptoms such as shortness of breath or chest pain. Establishing a correct diagnosis in these situations allows for timely therapeutic interventions and eliminates unnecessary diagnostic evaluation. Diagnostic errors account for more than 15% of all adverse events, and cognitive errors—resulting from faulty data gathering, flawed reasoning, or faulty verification—have a large role in most of these cases.^1-3 Hospitalists assess disease prevalence, pretest probability, and posttest probability to make a diagnostic decision while avoiding cognitive bias. By engaging in efficient and timely diagnostic decision-making, hospitalists can positively influence the quality and cost of medical care. 

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 prevalence of common disease states in the local patient population.

• Define and differentiate problem-solving strategies, including hypothesis testing and pattern recognition.

• Define and differentiate prevalence, pretest probability, test characteristics (including sensitivity, specificity, negative predictive value, positive predictive value, likelihood ratios), and posttest probability.

• Describe the relevance of sensitivity and specificity in interpreting diagnostic findings.

• Describe the sensitivity and specificity of key clinical features and diagnostic findings for common clinical syndromes.

• Describe the concepts that underlie Bayes’ theorem and explain how it is used in diagnostic decision-making.

• Describe the factors that account for excessive or indiscriminate testing.

• Describe types of cognitive biases that can influence decision-making.

Hospitalists should be able to:

• Elicit a targeted medical history and perform a physical examination to detect symptoms and data that help refine the diagnostic hypothesis.

• Access resources that contain relevant information such as prevalence and incidence rates of disease states.

• Analyze the value of each diagnostic test, especially testing procedures that carry clinically significant patient discomfort or risk.

• Formulate a pretest probability using initial history, physical examination, and preliminary diagnostic information when available.

• Calculate posttest probabilities of disease using pretest probabilities and likelihood ratios.

• Communicate with patients and families to explain the differential diagnosis and evaluation of the patient’s presenting symptoms.

• Communicate with patients and families to explain how testing will change the scope of diagnostic possibilities.

• Communicate with other physicians, trainees, and healthcare providers to explain the rationale for use of diagnostic tests.

• Anticipate, identify, and avoid cognitive biases when making diagnostic decisions.

• Incorporate the principles of evidence-based medicine, healthcare costs, and individual patient characteristics and preferences into each patient’s diagnostic evaluation.

• Determine when sufficient evaluation has occurred in the absence of diagnostic certainty.

• Lead, coordinate, and/or participate in the development of clinical care pathways designed to simplify and/or improve the diagnostic process for a particular clinical condition. 

Hospitalists should be able to:

• Recognize that each test should be preceded by a conscious decision to change or maintain the clinical care or initiate further diagnostic evaluation as indicated on the basis of test results.

• Appreciate that all tests have false-positive and false-negative results and rigorously scrutinize or repeat the test when the result is in question.

Diagnostic decision-making refers to the process of evaluating a patient complaint to develop a differential diagnosis, design a diagnostic evaluation, and arrive at a final diagnosis. Hospitalists frequently care for acutely ill patients with undifferentiated symptoms such as shortness of breath or chest pain. Establishing a correct diagnosis in these situations allows for timely therapeutic interventions and eliminates unnecessary diagnostic evaluation. Diagnostic errors account for more than 15% of all adverse events, and cognitive errors—resulting from faulty data gathering, flawed reasoning, or faulty verification—have a large role in most of these cases.^1-3 Hospitalists assess disease prevalence, pretest probability, and posttest probability to make a diagnostic decision while avoiding cognitive bias. By engaging in efficient and timely diagnostic decision-making, hospitalists can positively influence the quality and cost of medical care. 

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 prevalence of common disease states in the local patient population.

• Define and differentiate problem-solving strategies, including hypothesis testing and pattern recognition.

• Define and differentiate prevalence, pretest probability, test characteristics (including sensitivity, specificity, negative predictive value, positive predictive value, likelihood ratios), and posttest probability.

• Describe the relevance of sensitivity and specificity in interpreting diagnostic findings.

• Describe the sensitivity and specificity of key clinical features and diagnostic findings for common clinical syndromes.

• Describe the concepts that underlie Bayes’ theorem and explain how it is used in diagnostic decision-making.

• Describe the factors that account for excessive or indiscriminate testing.

• Describe types of cognitive biases that can influence decision-making.

Hospitalists should be able to:

• Elicit a targeted medical history and perform a physical examination to detect symptoms and data that help refine the diagnostic hypothesis.

• Access resources that contain relevant information such as prevalence and incidence rates of disease states.

• Analyze the value of each diagnostic test, especially testing procedures that carry clinically significant patient discomfort or risk.

• Formulate a pretest probability using initial history, physical examination, and preliminary diagnostic information when available.

• Calculate posttest probabilities of disease using pretest probabilities and likelihood ratios.

• Communicate with patients and families to explain the differential diagnosis and evaluation of the patient’s presenting symptoms.

• Communicate with patients and families to explain how testing will change the scope of diagnostic possibilities.

• Communicate with other physicians, trainees, and healthcare providers to explain the rationale for use of diagnostic tests.

• Anticipate, identify, and avoid cognitive biases when making diagnostic decisions.

• Incorporate the principles of evidence-based medicine, healthcare costs, and individual patient characteristics and preferences into each patient’s diagnostic evaluation.

• Determine when sufficient evaluation has occurred in the absence of diagnostic certainty.

• Lead, coordinate, and/or participate in the development of clinical care pathways designed to simplify and/or improve the diagnostic process for a particular clinical condition. 

Hospitalists should be able to:

• Recognize that each test should be preceded by a conscious decision to change or maintain the clinical care or initiate further diagnostic evaluation as indicated on the basis of test results.

• Appreciate that all tests have false-positive and false-negative results and rigorously scrutinize or repeat the test when the result is in question.

Diagnostic decision-making refers to the process of evaluating a patient complaint to develop a differential diagnosis, design a diagnostic evaluation, and arrive at a final diagnosis. Hospitalists frequently care for acutely ill patients with undifferentiated symptoms such as shortness of breath or chest pain. Establishing a correct diagnosis in these situations allows for timely therapeutic interventions and eliminates unnecessary diagnostic evaluation. Diagnostic errors account for more than 15% of all adverse events, and cognitive errors—resulting from faulty data gathering, flawed reasoning, or faulty verification—have a large role in most of these cases.^1-3 Hospitalists assess disease prevalence, pretest probability, and posttest probability to make a diagnostic decision while avoiding cognitive bias. By engaging in efficient and timely diagnostic decision-making, hospitalists can positively influence the quality and cost of medical care. 

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 prevalence of common disease states in the local patient population.

• Define and differentiate problem-solving strategies, including hypothesis testing and pattern recognition.

• Define and differentiate prevalence, pretest probability, test characteristics (including sensitivity, specificity, negative predictive value, positive predictive value, likelihood ratios), and posttest probability.

• Describe the relevance of sensitivity and specificity in interpreting diagnostic findings.

• Describe the sensitivity and specificity of key clinical features and diagnostic findings for common clinical syndromes.

• Describe the concepts that underlie Bayes’ theorem and explain how it is used in diagnostic decision-making.

• Describe the factors that account for excessive or indiscriminate testing.

• Describe types of cognitive biases that can influence decision-making.

Hospitalists should be able to:

• Elicit a targeted medical history and perform a physical examination to detect symptoms and data that help refine the diagnostic hypothesis.

• Access resources that contain relevant information such as prevalence and incidence rates of disease states.

• Analyze the value of each diagnostic test, especially testing procedures that carry clinically significant patient discomfort or risk.

• Formulate a pretest probability using initial history, physical examination, and preliminary diagnostic information when available.

• Calculate posttest probabilities of disease using pretest probabilities and likelihood ratios.

• Communicate with patients and families to explain the differential diagnosis and evaluation of the patient’s presenting symptoms.

• Communicate with patients and families to explain how testing will change the scope of diagnostic possibilities.

• Communicate with other physicians, trainees, and healthcare providers to explain the rationale for use of diagnostic tests.

• Anticipate, identify, and avoid cognitive biases when making diagnostic decisions.

• Incorporate the principles of evidence-based medicine, healthcare costs, and individual patient characteristics and preferences into each patient’s diagnostic evaluation.

• Determine when sufficient evaluation has occurred in the absence of diagnostic certainty.

• Lead, coordinate, and/or participate in the development of clinical care pathways designed to simplify and/or improve the diagnostic process for a particular clinical condition. 

Hospitalists should be able to:

• Recognize that each test should be preceded by a conscious decision to change or maintain the clinical care or initiate further diagnostic evaluation as indicated on the basis of test results.

• Appreciate that all tests have false-positive and false-negative results and rigorously scrutinize or repeat the test when the result is in question.

The availability and use of pharmaceutical agents has widely expanded in healthcare, as have concerns about adverse drug events (ADEs). When prescribing medications, hospitalists should strive to use evidence-based therapies and must evaluate the benefits, harms, and financial costs of drug therapy for individual patients. Annually in the United States, 380,000 to 450,000 preventable ADEs occur in hospitalized patients.¹ Notably, 82% of American adults take at least 1 medication and 29% take 5 or more, and drug-drug interactions account for 3% to 5% of ADEs.^2,3 The occurrence of ADEs is associated with increased mortality, morbidity, prolonged hospitalization, and higher costs of care.⁴ In clinical practice, hospitalists should promote and lead multidisciplinary teams to develop and implement protocols, guidelines, and clinical pathways that recommend preferred drug therapies. In addition, hospitalists should have familiarity in interpreting outcomes measurement (pharmacoepidemiology) and economic analyses (pharmacoeconomics). 

Hospitalists should be able to:

• Describe principles of evaluating clinical efficacy, pharmacokinetics, dosing, drug and food interactions, and adverse effects that can affect the choice of agent, dosing frequency, and route of administration.

• Explain the evidence-based rationale for prophylactic drug therapies, comparing the costs, risks, and benefits of competing strategies.

• Explain how pharmacodynamics may change with age, liver disease, and renal insufficiency.

• Describe the incidence of various types of ADEs in hospitalized patients, which may include adverse effects, interactions, and errors.

• Recognize the risk of ADEs during care transitions.

• Explain the role of polypharmacy in the development of delirium, ADEs, and noncompliance.

• Describe how the overuse of antibiotics promotes antibiotic resistance.

• Describe potential complications associated with administration of blood products.

• Describe key principles for interpreting pharmacoeconomic analyses, including inflation rate, discounting rate, incremental analysis, sensitivity analysis, and inherent bias.

• Describe the clinical efficacy, safety profile, pharmacokinetics, dosing, drug and food interactions, and costs of commonly prescribed medications and biological agents (eg, blood products).

Hospitalists should be able to:

• Adjust prescribing strategies for patients according to conditions that may influence pharmacokinetics, such as age or comorbidities.

• Apply treatment guidelines to individual patients to use antibiotics judiciously to reduce cost and the emergence of antibiotic resistance.

• Integrate knowledge of benefits and risks of drug therapies into medical decision-making for individual patients and routinely reassess decisions.

• Minimize ADEs by following best practice models of medication ordering and administration.

• Document medications accurately and legibly, taking into account approved abbreviations, and indicate start and stop dates for short-term medications.

• Arrange appropriate follow-up for therapies that require outpatient monitoring, dosage adjustment, and education (eg, anticoagulants, antibiotics).

• Balance the benefits, risks, and cost of prophylactic therapies, which may include venous thromboembolism and stress ulcer prophylaxis.

• Convert intravenous medications to the oral route when indicated to promote patient safety, satisfaction, and reduce cost.

• Follow standard practices for transfusion of blood products.

• Educate patients and families regarding the indications, benefits, potential adverse effects, alternatives, and directions for use of the prescribed medications.

• Educate patients and families about the importance of acquiring medication information and communicating medication history to clinicians at each transition of care.

• Reconcile outpatient medications with inpatient medications at the time of admission and discharge.

• Critically assess and apply results of outcome studies to improve drug treatment and safety for individual patients.

• Lead, coordinate, and/or participate in the development, use, and dissemination of local, regional, and national practice guidelines and patient safety alerts pertaining to the prevention of complications.

• Apply principles of pharmacoepidemiology and pharmacoeconomics to implement practice guidelines and protocols for a hospital. 

Hospitalists should be able to:

• Appreciate that ADEs must be monitored and that steps must be taken to reduce their incidence.

• Exemplify safe medication prescribing and administration practices.

• Engage collaboratively with multidisciplinary teams, which may include pharmacy, nursing service, social work, case management, long-term care facilities, and outpatient care teams, to improve drug safety for individual patients and reduce costs.

The availability and use of pharmaceutical agents has widely expanded in healthcare, as have concerns about adverse drug events (ADEs). When prescribing medications, hospitalists should strive to use evidence-based therapies and must evaluate the benefits, harms, and financial costs of drug therapy for individual patients. Annually in the United States, 380,000 to 450,000 preventable ADEs occur in hospitalized patients.¹ Notably, 82% of American adults take at least 1 medication and 29% take 5 or more, and drug-drug interactions account for 3% to 5% of ADEs.^2,3 The occurrence of ADEs is associated with increased mortality, morbidity, prolonged hospitalization, and higher costs of care.⁴ In clinical practice, hospitalists should promote and lead multidisciplinary teams to develop and implement protocols, guidelines, and clinical pathways that recommend preferred drug therapies. In addition, hospitalists should have familiarity in interpreting outcomes measurement (pharmacoepidemiology) and economic analyses (pharmacoeconomics). 

Hospitalists should be able to:

• Describe principles of evaluating clinical efficacy, pharmacokinetics, dosing, drug and food interactions, and adverse effects that can affect the choice of agent, dosing frequency, and route of administration.

• Explain the evidence-based rationale for prophylactic drug therapies, comparing the costs, risks, and benefits of competing strategies.

• Explain how pharmacodynamics may change with age, liver disease, and renal insufficiency.

• Describe the incidence of various types of ADEs in hospitalized patients, which may include adverse effects, interactions, and errors.

• Recognize the risk of ADEs during care transitions.

• Explain the role of polypharmacy in the development of delirium, ADEs, and noncompliance.

• Describe how the overuse of antibiotics promotes antibiotic resistance.

• Describe potential complications associated with administration of blood products.

• Describe key principles for interpreting pharmacoeconomic analyses, including inflation rate, discounting rate, incremental analysis, sensitivity analysis, and inherent bias.

• Describe the clinical efficacy, safety profile, pharmacokinetics, dosing, drug and food interactions, and costs of commonly prescribed medications and biological agents (eg, blood products).

Hospitalists should be able to:

• Adjust prescribing strategies for patients according to conditions that may influence pharmacokinetics, such as age or comorbidities.

• Apply treatment guidelines to individual patients to use antibiotics judiciously to reduce cost and the emergence of antibiotic resistance.

• Integrate knowledge of benefits and risks of drug therapies into medical decision-making for individual patients and routinely reassess decisions.

• Minimize ADEs by following best practice models of medication ordering and administration.

• Document medications accurately and legibly, taking into account approved abbreviations, and indicate start and stop dates for short-term medications.

• Arrange appropriate follow-up for therapies that require outpatient monitoring, dosage adjustment, and education (eg, anticoagulants, antibiotics).

• Balance the benefits, risks, and cost of prophylactic therapies, which may include venous thromboembolism and stress ulcer prophylaxis.

• Convert intravenous medications to the oral route when indicated to promote patient safety, satisfaction, and reduce cost.

• Follow standard practices for transfusion of blood products.

• Educate patients and families regarding the indications, benefits, potential adverse effects, alternatives, and directions for use of the prescribed medications.

• Educate patients and families about the importance of acquiring medication information and communicating medication history to clinicians at each transition of care.

• Reconcile outpatient medications with inpatient medications at the time of admission and discharge.

• Critically assess and apply results of outcome studies to improve drug treatment and safety for individual patients.

• Lead, coordinate, and/or participate in the development, use, and dissemination of local, regional, and national practice guidelines and patient safety alerts pertaining to the prevention of complications.

• Apply principles of pharmacoepidemiology and pharmacoeconomics to implement practice guidelines and protocols for a hospital. 

Hospitalists should be able to:

• Appreciate that ADEs must be monitored and that steps must be taken to reduce their incidence.

• Exemplify safe medication prescribing and administration practices.

• Engage collaboratively with multidisciplinary teams, which may include pharmacy, nursing service, social work, case management, long-term care facilities, and outpatient care teams, to improve drug safety for individual patients and reduce costs.

The availability and use of pharmaceutical agents has widely expanded in healthcare, as have concerns about adverse drug events (ADEs). When prescribing medications, hospitalists should strive to use evidence-based therapies and must evaluate the benefits, harms, and financial costs of drug therapy for individual patients. Annually in the United States, 380,000 to 450,000 preventable ADEs occur in hospitalized patients.¹ Notably, 82% of American adults take at least 1 medication and 29% take 5 or more, and drug-drug interactions account for 3% to 5% of ADEs.^2,3 The occurrence of ADEs is associated with increased mortality, morbidity, prolonged hospitalization, and higher costs of care.⁴ In clinical practice, hospitalists should promote and lead multidisciplinary teams to develop and implement protocols, guidelines, and clinical pathways that recommend preferred drug therapies. In addition, hospitalists should have familiarity in interpreting outcomes measurement (pharmacoepidemiology) and economic analyses (pharmacoeconomics). 

Hospitalists should be able to:

• Describe principles of evaluating clinical efficacy, pharmacokinetics, dosing, drug and food interactions, and adverse effects that can affect the choice of agent, dosing frequency, and route of administration.

• Explain the evidence-based rationale for prophylactic drug therapies, comparing the costs, risks, and benefits of competing strategies.

• Explain how pharmacodynamics may change with age, liver disease, and renal insufficiency.

• Describe the incidence of various types of ADEs in hospitalized patients, which may include adverse effects, interactions, and errors.

• Recognize the risk of ADEs during care transitions.

• Explain the role of polypharmacy in the development of delirium, ADEs, and noncompliance.

• Describe how the overuse of antibiotics promotes antibiotic resistance.

• Describe potential complications associated with administration of blood products.

• Describe key principles for interpreting pharmacoeconomic analyses, including inflation rate, discounting rate, incremental analysis, sensitivity analysis, and inherent bias.

• Describe the clinical efficacy, safety profile, pharmacokinetics, dosing, drug and food interactions, and costs of commonly prescribed medications and biological agents (eg, blood products).

Hospitalists should be able to:

• Adjust prescribing strategies for patients according to conditions that may influence pharmacokinetics, such as age or comorbidities.

• Apply treatment guidelines to individual patients to use antibiotics judiciously to reduce cost and the emergence of antibiotic resistance.

• Integrate knowledge of benefits and risks of drug therapies into medical decision-making for individual patients and routinely reassess decisions.

• Minimize ADEs by following best practice models of medication ordering and administration.

• Document medications accurately and legibly, taking into account approved abbreviations, and indicate start and stop dates for short-term medications.

• Arrange appropriate follow-up for therapies that require outpatient monitoring, dosage adjustment, and education (eg, anticoagulants, antibiotics).

• Balance the benefits, risks, and cost of prophylactic therapies, which may include venous thromboembolism and stress ulcer prophylaxis.

• Convert intravenous medications to the oral route when indicated to promote patient safety, satisfaction, and reduce cost.

• Follow standard practices for transfusion of blood products.

• Educate patients and families regarding the indications, benefits, potential adverse effects, alternatives, and directions for use of the prescribed medications.

• Educate patients and families about the importance of acquiring medication information and communicating medication history to clinicians at each transition of care.

• Reconcile outpatient medications with inpatient medications at the time of admission and discharge.

• Critically assess and apply results of outcome studies to improve drug treatment and safety for individual patients.

• Lead, coordinate, and/or participate in the development, use, and dissemination of local, regional, and national practice guidelines and patient safety alerts pertaining to the prevention of complications.

• Apply principles of pharmacoepidemiology and pharmacoeconomics to implement practice guidelines and protocols for a hospital. 

Hospitalists should be able to:

• Appreciate that ADEs must be monitored and that steps must be taken to reduce their incidence.

• Exemplify safe medication prescribing and administration practices.

• Engage collaboratively with multidisciplinary teams, which may include pharmacy, nursing service, social work, case management, long-term care facilities, and outpatient care teams, to improve drug safety for individual patients and reduce costs.