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Kawasaki disease
Introduction
Kawasaki Disease (KD), also known as mucocutaneous lymph node syndrome, is a multisystem inflammatory disease of childhood. It most commonly presents in children under the age of two, however has been seen up to 12 years of age. Diagnosis can be difficult, as the classic signs and symptoms may not all manifest and the presentation may mimic other causes of fever and rash. Although many organs may be affected, those related to the cardiac system are the most concerning and persistent. Coronary aneurysms have been reported to occur in up to 20% of untreated children with KD. If diagnosed and treated promptly, the cardiac complications can be reduced. Therefore, it is important that pediatric hospitalists have a complete understanding of the diagnostic criteria and treatment of KD.
Knowledge
Pediatric hospitalists should be able to:
Discuss current established criteria and guidelines for diagnosis and treatment.
Define incomplete KD and note age groups in which this is more common.
List the broad categories of alternate diagnoses, and give examples from each.
Discuss the appropriate laboratory and imaging studies that aid in diagnosis.
Explain the pathophysiology of the disease, including the current understanding of development and manifestation of cardiac complications.
Define refractory KD and the list factors that indicate the need for further treatment.
Describe current best practice treatments, including approach toward persistent fever.
Compare and contrast the risks, benefits, and side effects of available treatments such as immunoglobulin, steroids, anti‐platelet medications and immunomodulators.
Cite risk factors associated with increased cardiac complications.
Discuss the immediate and long term follow‐up needed including impact, if any, on physical activity and sports participation.
List appropriate discharge criteria for KD.
Skills
Pediatric hospitalists should be able to:
Correctly diagnose KD by efficiently performing an accurate history and physical examination, determining if key features of the disease are present.
Promptly consult appropriate subspecialists to assist in evaluation and treatment.
Correctly interpret laboratory and imaging results.
Recognize features of alternate diagnoses and order relevant diagnostic studies as indicated.
Perform careful reassessments daily and as needed, note changes in clinical status and respond with appropriate actions.
Initiate prompt treatment once the diagnosis is established.
Anticipate and treat complications and side effects of instituted therapies.
Identify treatment failure and institute appropriate repeat or alternate therapy.
Demonstrate basic proficiency in reading electrocardiograms.
Coordinate care with subspecialists and the primary care provider, and arrange an appropriate transition and follow‐up plans for after hospital discharge.
Attitudes
Pediatric hospitalists should be able to:
Communicate effectively with patients, the family/caregiver, and other healthcare providers regarding findings and care plans.
Educate patients and the family/caregiver on the natural course of disease.
Collaborate with subspecialists and the primary care provider to ensure coordinated longitudinal care for children with KD.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Lead, coordinate or participate in early multidisciplinary care to promote efficient diagnosis, treatment and discharge of patients with KD.
Work with hospital staff and subspecialists to educate other healthcare providers regarding the diagnosis and treatment of KD.
Lead, coordinate or participate in community education efforts regarding KD.
Introduction
Kawasaki Disease (KD), also known as mucocutaneous lymph node syndrome, is a multisystem inflammatory disease of childhood. It most commonly presents in children under the age of two, however has been seen up to 12 years of age. Diagnosis can be difficult, as the classic signs and symptoms may not all manifest and the presentation may mimic other causes of fever and rash. Although many organs may be affected, those related to the cardiac system are the most concerning and persistent. Coronary aneurysms have been reported to occur in up to 20% of untreated children with KD. If diagnosed and treated promptly, the cardiac complications can be reduced. Therefore, it is important that pediatric hospitalists have a complete understanding of the diagnostic criteria and treatment of KD.
Knowledge
Pediatric hospitalists should be able to:
Discuss current established criteria and guidelines for diagnosis and treatment.
Define incomplete KD and note age groups in which this is more common.
List the broad categories of alternate diagnoses, and give examples from each.
Discuss the appropriate laboratory and imaging studies that aid in diagnosis.
Explain the pathophysiology of the disease, including the current understanding of development and manifestation of cardiac complications.
Define refractory KD and the list factors that indicate the need for further treatment.
Describe current best practice treatments, including approach toward persistent fever.
Compare and contrast the risks, benefits, and side effects of available treatments such as immunoglobulin, steroids, anti‐platelet medications and immunomodulators.
Cite risk factors associated with increased cardiac complications.
Discuss the immediate and long term follow‐up needed including impact, if any, on physical activity and sports participation.
List appropriate discharge criteria for KD.
Skills
Pediatric hospitalists should be able to:
Correctly diagnose KD by efficiently performing an accurate history and physical examination, determining if key features of the disease are present.
Promptly consult appropriate subspecialists to assist in evaluation and treatment.
Correctly interpret laboratory and imaging results.
Recognize features of alternate diagnoses and order relevant diagnostic studies as indicated.
Perform careful reassessments daily and as needed, note changes in clinical status and respond with appropriate actions.
Initiate prompt treatment once the diagnosis is established.
Anticipate and treat complications and side effects of instituted therapies.
Identify treatment failure and institute appropriate repeat or alternate therapy.
Demonstrate basic proficiency in reading electrocardiograms.
Coordinate care with subspecialists and the primary care provider, and arrange an appropriate transition and follow‐up plans for after hospital discharge.
Attitudes
Pediatric hospitalists should be able to:
Communicate effectively with patients, the family/caregiver, and other healthcare providers regarding findings and care plans.
Educate patients and the family/caregiver on the natural course of disease.
Collaborate with subspecialists and the primary care provider to ensure coordinated longitudinal care for children with KD.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Lead, coordinate or participate in early multidisciplinary care to promote efficient diagnosis, treatment and discharge of patients with KD.
Work with hospital staff and subspecialists to educate other healthcare providers regarding the diagnosis and treatment of KD.
Lead, coordinate or participate in community education efforts regarding KD.
Introduction
Kawasaki Disease (KD), also known as mucocutaneous lymph node syndrome, is a multisystem inflammatory disease of childhood. It most commonly presents in children under the age of two, however has been seen up to 12 years of age. Diagnosis can be difficult, as the classic signs and symptoms may not all manifest and the presentation may mimic other causes of fever and rash. Although many organs may be affected, those related to the cardiac system are the most concerning and persistent. Coronary aneurysms have been reported to occur in up to 20% of untreated children with KD. If diagnosed and treated promptly, the cardiac complications can be reduced. Therefore, it is important that pediatric hospitalists have a complete understanding of the diagnostic criteria and treatment of KD.
Knowledge
Pediatric hospitalists should be able to:
Discuss current established criteria and guidelines for diagnosis and treatment.
Define incomplete KD and note age groups in which this is more common.
List the broad categories of alternate diagnoses, and give examples from each.
Discuss the appropriate laboratory and imaging studies that aid in diagnosis.
Explain the pathophysiology of the disease, including the current understanding of development and manifestation of cardiac complications.
Define refractory KD and the list factors that indicate the need for further treatment.
Describe current best practice treatments, including approach toward persistent fever.
Compare and contrast the risks, benefits, and side effects of available treatments such as immunoglobulin, steroids, anti‐platelet medications and immunomodulators.
Cite risk factors associated with increased cardiac complications.
Discuss the immediate and long term follow‐up needed including impact, if any, on physical activity and sports participation.
List appropriate discharge criteria for KD.
Skills
Pediatric hospitalists should be able to:
Correctly diagnose KD by efficiently performing an accurate history and physical examination, determining if key features of the disease are present.
Promptly consult appropriate subspecialists to assist in evaluation and treatment.
Correctly interpret laboratory and imaging results.
Recognize features of alternate diagnoses and order relevant diagnostic studies as indicated.
Perform careful reassessments daily and as needed, note changes in clinical status and respond with appropriate actions.
Initiate prompt treatment once the diagnosis is established.
Anticipate and treat complications and side effects of instituted therapies.
Identify treatment failure and institute appropriate repeat or alternate therapy.
Demonstrate basic proficiency in reading electrocardiograms.
Coordinate care with subspecialists and the primary care provider, and arrange an appropriate transition and follow‐up plans for after hospital discharge.
Attitudes
Pediatric hospitalists should be able to:
Communicate effectively with patients, the family/caregiver, and other healthcare providers regarding findings and care plans.
Educate patients and the family/caregiver on the natural course of disease.
Collaborate with subspecialists and the primary care provider to ensure coordinated longitudinal care for children with KD.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Lead, coordinate or participate in early multidisciplinary care to promote efficient diagnosis, treatment and discharge of patients with KD.
Work with hospital staff and subspecialists to educate other healthcare providers regarding the diagnosis and treatment of KD.
Lead, coordinate or participate in community education efforts regarding KD.
Copyright © 2010 Society of Hospital Medicine
Urinary tract infections
Introduction
Infections of the urinary tract can involve any structure from the kidney to the urethra. Pyelonephritis exists when the infection involves the kidney. Urinary tract infections (UTI) occur in up to 2.8% of all children and 5% of febrile children. They result in 1.1 million office visits (0.7% of total visits) and 13,000 hospitalizations annually. Costs related to only the acute inpatient care of UTI are estimated at $180 million per year alone. The financial impact of subsequent follow‐up imaging, treatment, long‐term sequelae, and family/caregiver work loss is not well quantitated but is substantial. UTIs may be associated with urologic abnormalities in a significant percentage of young children with pyelonephritis. Pediatric hospitalists frequently encounter children with UTI and must remain current on strategies for diagnosis, treatment and follow‐up care for patients with UTIs.
Knowledge
Pediatric hospitalists should be able to:
Describe the abnormal anatomic and physiologic aspects of the urogenital system that may predispose children to UTIs at varying ages, such as posterior urethral valves, duplicated system, voiding dysfunction, chronic constipation, and others.
Describe the range of clinical presentations attending to differences by age.
Compare and contrast the short and long terms risks of lower versus upper urinary tract infection.
Define a positive urine culture and discuss how the method for obtaining and efficiency of processing urine influences results of cultures.
Identify pathogens that cause UTI in both the previously healthy host and those with underlying disease.
Describe appropriate antibiotic coverage for pathogens of concern with awareness of antibiotic resistance patterns within the local community.
Discuss the utility of commonly obtained laboratory tests such as urinalysis, urine gram stain, urine culture, blood culture, serum chemistries, and others.
Review the typical response to therapy, and list common complications of ineffective treatment.
Summarize current literature regarding treatment and evaluation for underlying abnormalities, including radiography.
List factors warranting subspecialty consultation or referral.
Discuss the potential acute and long‐term sequelae of treated and untreated UTI.
Summarize the discharge plan attending to indications for short and long term parenteral and total antimicrobial therapy, repeat evaluations, and subspecialty referral by age.
Skills
Pediatric hospitalists should be able to:
Correctly diagnose UTI by efficiently performing an accurate history and physical examination, determining if key features of the disease are present.
Identify patients at risk for UTI.
Order appropriate diagnostic studies for the evaluation of suspected UTI.
Prescribe appropriate initial antimicrobial and supportive therapy based on history and physical examination.
Correctly interpret results of diagnostic testing and use results to guide diagnosis and management.
Correctly identify the need for and efficiently access appropriate consultants and support services needed to provide comprehensive care.
Identify when discharge criteria are met, and initiate efficient discharge orders and plans.
Communicate effectively with patients, the family/caregiver and the primary care provider to ensure appropriate post‐discharge testing and follow‐up.
Attitudes
Pediatric hospitalists should be able to:
Educate the family/caregiver on the expected course of illness, treatment options, and potential sequelae.
Recognize the importance of communicating with the primary care provider to ensure a safe, efficient, and effective discharge and post‐discharge care.
Collaborate with the healthcare team to ensure coordinated hospital care for children with UTI.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Collaborate with referring physicians (primary care, emergency medicine, and referring hospital physicians) to develop and sustain appropriate referral networks for evaluation, admission, or transfer of children with UTI.
Collaborate with subspecialists to ensure consistent, timely, and up‐to‐date evaluation and care in the inpatient setting.
Lead, coordinate or participate in the development and implementation of cost‐effective, safe, evidence‐based care pathways to standardize the evaluation and management of hospitalized children with UTI.
Introduction
Infections of the urinary tract can involve any structure from the kidney to the urethra. Pyelonephritis exists when the infection involves the kidney. Urinary tract infections (UTI) occur in up to 2.8% of all children and 5% of febrile children. They result in 1.1 million office visits (0.7% of total visits) and 13,000 hospitalizations annually. Costs related to only the acute inpatient care of UTI are estimated at $180 million per year alone. The financial impact of subsequent follow‐up imaging, treatment, long‐term sequelae, and family/caregiver work loss is not well quantitated but is substantial. UTIs may be associated with urologic abnormalities in a significant percentage of young children with pyelonephritis. Pediatric hospitalists frequently encounter children with UTI and must remain current on strategies for diagnosis, treatment and follow‐up care for patients with UTIs.
Knowledge
Pediatric hospitalists should be able to:
Describe the abnormal anatomic and physiologic aspects of the urogenital system that may predispose children to UTIs at varying ages, such as posterior urethral valves, duplicated system, voiding dysfunction, chronic constipation, and others.
Describe the range of clinical presentations attending to differences by age.
Compare and contrast the short and long terms risks of lower versus upper urinary tract infection.
Define a positive urine culture and discuss how the method for obtaining and efficiency of processing urine influences results of cultures.
Identify pathogens that cause UTI in both the previously healthy host and those with underlying disease.
Describe appropriate antibiotic coverage for pathogens of concern with awareness of antibiotic resistance patterns within the local community.
Discuss the utility of commonly obtained laboratory tests such as urinalysis, urine gram stain, urine culture, blood culture, serum chemistries, and others.
Review the typical response to therapy, and list common complications of ineffective treatment.
Summarize current literature regarding treatment and evaluation for underlying abnormalities, including radiography.
List factors warranting subspecialty consultation or referral.
Discuss the potential acute and long‐term sequelae of treated and untreated UTI.
Summarize the discharge plan attending to indications for short and long term parenteral and total antimicrobial therapy, repeat evaluations, and subspecialty referral by age.
Skills
Pediatric hospitalists should be able to:
Correctly diagnose UTI by efficiently performing an accurate history and physical examination, determining if key features of the disease are present.
Identify patients at risk for UTI.
Order appropriate diagnostic studies for the evaluation of suspected UTI.
Prescribe appropriate initial antimicrobial and supportive therapy based on history and physical examination.
Correctly interpret results of diagnostic testing and use results to guide diagnosis and management.
Correctly identify the need for and efficiently access appropriate consultants and support services needed to provide comprehensive care.
Identify when discharge criteria are met, and initiate efficient discharge orders and plans.
Communicate effectively with patients, the family/caregiver and the primary care provider to ensure appropriate post‐discharge testing and follow‐up.
Attitudes
Pediatric hospitalists should be able to:
Educate the family/caregiver on the expected course of illness, treatment options, and potential sequelae.
Recognize the importance of communicating with the primary care provider to ensure a safe, efficient, and effective discharge and post‐discharge care.
Collaborate with the healthcare team to ensure coordinated hospital care for children with UTI.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Collaborate with referring physicians (primary care, emergency medicine, and referring hospital physicians) to develop and sustain appropriate referral networks for evaluation, admission, or transfer of children with UTI.
Collaborate with subspecialists to ensure consistent, timely, and up‐to‐date evaluation and care in the inpatient setting.
Lead, coordinate or participate in the development and implementation of cost‐effective, safe, evidence‐based care pathways to standardize the evaluation and management of hospitalized children with UTI.
Introduction
Infections of the urinary tract can involve any structure from the kidney to the urethra. Pyelonephritis exists when the infection involves the kidney. Urinary tract infections (UTI) occur in up to 2.8% of all children and 5% of febrile children. They result in 1.1 million office visits (0.7% of total visits) and 13,000 hospitalizations annually. Costs related to only the acute inpatient care of UTI are estimated at $180 million per year alone. The financial impact of subsequent follow‐up imaging, treatment, long‐term sequelae, and family/caregiver work loss is not well quantitated but is substantial. UTIs may be associated with urologic abnormalities in a significant percentage of young children with pyelonephritis. Pediatric hospitalists frequently encounter children with UTI and must remain current on strategies for diagnosis, treatment and follow‐up care for patients with UTIs.
Knowledge
Pediatric hospitalists should be able to:
Describe the abnormal anatomic and physiologic aspects of the urogenital system that may predispose children to UTIs at varying ages, such as posterior urethral valves, duplicated system, voiding dysfunction, chronic constipation, and others.
Describe the range of clinical presentations attending to differences by age.
Compare and contrast the short and long terms risks of lower versus upper urinary tract infection.
Define a positive urine culture and discuss how the method for obtaining and efficiency of processing urine influences results of cultures.
Identify pathogens that cause UTI in both the previously healthy host and those with underlying disease.
Describe appropriate antibiotic coverage for pathogens of concern with awareness of antibiotic resistance patterns within the local community.
Discuss the utility of commonly obtained laboratory tests such as urinalysis, urine gram stain, urine culture, blood culture, serum chemistries, and others.
Review the typical response to therapy, and list common complications of ineffective treatment.
Summarize current literature regarding treatment and evaluation for underlying abnormalities, including radiography.
List factors warranting subspecialty consultation or referral.
Discuss the potential acute and long‐term sequelae of treated and untreated UTI.
Summarize the discharge plan attending to indications for short and long term parenteral and total antimicrobial therapy, repeat evaluations, and subspecialty referral by age.
Skills
Pediatric hospitalists should be able to:
Correctly diagnose UTI by efficiently performing an accurate history and physical examination, determining if key features of the disease are present.
Identify patients at risk for UTI.
Order appropriate diagnostic studies for the evaluation of suspected UTI.
Prescribe appropriate initial antimicrobial and supportive therapy based on history and physical examination.
Correctly interpret results of diagnostic testing and use results to guide diagnosis and management.
Correctly identify the need for and efficiently access appropriate consultants and support services needed to provide comprehensive care.
Identify when discharge criteria are met, and initiate efficient discharge orders and plans.
Communicate effectively with patients, the family/caregiver and the primary care provider to ensure appropriate post‐discharge testing and follow‐up.
Attitudes
Pediatric hospitalists should be able to:
Educate the family/caregiver on the expected course of illness, treatment options, and potential sequelae.
Recognize the importance of communicating with the primary care provider to ensure a safe, efficient, and effective discharge and post‐discharge care.
Collaborate with the healthcare team to ensure coordinated hospital care for children with UTI.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Collaborate with referring physicians (primary care, emergency medicine, and referring hospital physicians) to develop and sustain appropriate referral networks for evaluation, admission, or transfer of children with UTI.
Collaborate with subspecialists to ensure consistent, timely, and up‐to‐date evaluation and care in the inpatient setting.
Lead, coordinate or participate in the development and implementation of cost‐effective, safe, evidence‐based care pathways to standardize the evaluation and management of hospitalized children with UTI.
Copyright © 2010 Society of Hospital Medicine
Introduction to the Pediatric Hospital Medicine Core Competencies
Background
Pediatric Hospital Medicine continues to evolve as an area of specialization, with the refinement of a distinct knowledgebase and skill set focused on the provision of high quality general pediatric care in the inpatient setting. It is the latest site‐specific specialty to emerge from the field of general pediatrics, following a course similar to that charted by pediatric emergency medicine and pediatric critical care medicine in recent decades. The growth of the field has been spurred by a number of factors, including the converging needs for a dedicated emphasis on patient safety, quality improvement, throughput management, and teaching in the inpatient setting.
The number of practicing pediatric hospitalists is estimated to be approximately 2500 and rapidly increasing. To meet the educational needs of this growing cohort of pediatricians, local, regional, and national continuing medical education offerings occur on a regular basis. Furthermore, at least ten fellowships dedicated to advanced training in pediatric hospital medicine have been developed at academic institutions across North America. Despite this, there has been an absence of an accepted and peer‐reviewed framework for professional and curriculum development.
The Pediatric Hospital Medicine Core Competencies represent the first comprehensive attempt to more formally define the standards for the knowledge, skills, attitudes, and focus on systems improvements that are expected of all pediatric hospitalists, regardless of practice setting or location. It is the culmination of more than five years of planning, research, and development by the Society of Hospital Medicine Pediatric Core Curriculum Task Force, leaders within the Academic Pediatric Association and the American Academy of Pediatrics, and the editorial board. The competencies include contributions from over 80 pediatric hospitalists, content experts, and internal and external reviewers representing university and community hospitals, teaching and non‐teaching programs, and key societies and agencies involved in child health from all geographic regions of the United States and Canada. A companion article to Pediatric Hospital Medicine Core Competencies in this Supplement provides additional details regarding the project methodology.
Purpose
The Pediatric Hospital Medicine Core Competencies provide a framework for professional and curriculum development for all pediatric hospitalists. The framework is intended for use by hospital medicine program directors, directors of medical student clerkships, residency programs, fellowships, and continuing medical education, as well as other educators involved in curriculum development. The competencies do not focus on specific content, but rather general learning objectives within the skills, knowledge, and attitudes related to each topic. Attaining competency in the areas defined in these chapters is expected to require post‐residency training. This training is most likely to be obtained through a combination of work experience, local mentorship, and engagement in specific educational programs or fellowship. Pediatric hospitalists, directors, and educators can create specific instructional activities and methods chosen to reflect the characteristics of the intended learners and context of the practice environment.
Organization Structure
The Pediatric Hospital Medicine Core Competencies consist of 54 chapters, divided into four sections Common Clinical Diagnoses and Conditions, Specialized Clinical Services, Core Skills, and Healthcare Systems: Supporting and Advancing Child Health. Within each section, individual chapters on focused topics provide competencies in three domains of educational outcomes: the Cognitive Domain (Knowledge), the Psychomotor Domain (Skills), and the Affective Domain (Attitudes). To reflect the emphasis of hospital medicine practice on improving healthcare systems, a fourth section entitled Systems Organization and Improvement is also included. An attempt has been made to make the objectives timeless, allowing for creation of curriculum that can be nimble and reactive to new discoveries. Highly specific temporal changes in medicine are purposefully excluded, and instead the focus is on the drivers for these changes or advancements. Phrases and wording were selected to help guide the learning activities most likely to achieve each competency and to reflect the varied roles that pediatric hospitalists have in different practice settings. In this document, the terms child and children include infants, children, adolescents, and young adults up to the age of 21, in accordance of policies of the American Academy of Pediatrics. However, it is also understood that care is rendered in pediatric settings for patients who may surpass this upper age limit based on diagnosis or special healthcare needs. Finally, although the entire document can be a resource for comprehensive program development, each chapter is intended to stand alone and thus support curriculum development specific to the needs of individual programs.
Conclusion and Acknowledgement
The Pediatric Hospital Medicine Core Competencies are intended to provide standards for the knowledge, skills, and attitudes expected of all pediatric hospitalists and to provide a framework for ongoing professional and curriculum development for learners at all levels. We welcome feedback and evaluation from pediatric hospitalists and from all with whom we partner to improve the care for hospitalized children.
We wish to acknowledge the dedication of authors and associate editors, and the thoughtful review by the members of hospital organizations, accrediting bodies, and agencies listed in this supplement. This inaugural edition of the Pediatric Hospital Medicine Core Competenciesshould serve as the foundation from which the field of Pediatric Hospital Medicine will continue to evolve. We look forward with anticipation to future revisions as we reflect on our goals and advance our field.
The Pediatric Hospital Medicine Core Competencies Editorial Board
Erin Stucky, MD
Mary C Ottolini, MD, MPH
Jennifer Maniscalco, MD, MPH
Background
Pediatric Hospital Medicine continues to evolve as an area of specialization, with the refinement of a distinct knowledgebase and skill set focused on the provision of high quality general pediatric care in the inpatient setting. It is the latest site‐specific specialty to emerge from the field of general pediatrics, following a course similar to that charted by pediatric emergency medicine and pediatric critical care medicine in recent decades. The growth of the field has been spurred by a number of factors, including the converging needs for a dedicated emphasis on patient safety, quality improvement, throughput management, and teaching in the inpatient setting.
The number of practicing pediatric hospitalists is estimated to be approximately 2500 and rapidly increasing. To meet the educational needs of this growing cohort of pediatricians, local, regional, and national continuing medical education offerings occur on a regular basis. Furthermore, at least ten fellowships dedicated to advanced training in pediatric hospital medicine have been developed at academic institutions across North America. Despite this, there has been an absence of an accepted and peer‐reviewed framework for professional and curriculum development.
The Pediatric Hospital Medicine Core Competencies represent the first comprehensive attempt to more formally define the standards for the knowledge, skills, attitudes, and focus on systems improvements that are expected of all pediatric hospitalists, regardless of practice setting or location. It is the culmination of more than five years of planning, research, and development by the Society of Hospital Medicine Pediatric Core Curriculum Task Force, leaders within the Academic Pediatric Association and the American Academy of Pediatrics, and the editorial board. The competencies include contributions from over 80 pediatric hospitalists, content experts, and internal and external reviewers representing university and community hospitals, teaching and non‐teaching programs, and key societies and agencies involved in child health from all geographic regions of the United States and Canada. A companion article to Pediatric Hospital Medicine Core Competencies in this Supplement provides additional details regarding the project methodology.
Purpose
The Pediatric Hospital Medicine Core Competencies provide a framework for professional and curriculum development for all pediatric hospitalists. The framework is intended for use by hospital medicine program directors, directors of medical student clerkships, residency programs, fellowships, and continuing medical education, as well as other educators involved in curriculum development. The competencies do not focus on specific content, but rather general learning objectives within the skills, knowledge, and attitudes related to each topic. Attaining competency in the areas defined in these chapters is expected to require post‐residency training. This training is most likely to be obtained through a combination of work experience, local mentorship, and engagement in specific educational programs or fellowship. Pediatric hospitalists, directors, and educators can create specific instructional activities and methods chosen to reflect the characteristics of the intended learners and context of the practice environment.
Organization Structure
The Pediatric Hospital Medicine Core Competencies consist of 54 chapters, divided into four sections Common Clinical Diagnoses and Conditions, Specialized Clinical Services, Core Skills, and Healthcare Systems: Supporting and Advancing Child Health. Within each section, individual chapters on focused topics provide competencies in three domains of educational outcomes: the Cognitive Domain (Knowledge), the Psychomotor Domain (Skills), and the Affective Domain (Attitudes). To reflect the emphasis of hospital medicine practice on improving healthcare systems, a fourth section entitled Systems Organization and Improvement is also included. An attempt has been made to make the objectives timeless, allowing for creation of curriculum that can be nimble and reactive to new discoveries. Highly specific temporal changes in medicine are purposefully excluded, and instead the focus is on the drivers for these changes or advancements. Phrases and wording were selected to help guide the learning activities most likely to achieve each competency and to reflect the varied roles that pediatric hospitalists have in different practice settings. In this document, the terms child and children include infants, children, adolescents, and young adults up to the age of 21, in accordance of policies of the American Academy of Pediatrics. However, it is also understood that care is rendered in pediatric settings for patients who may surpass this upper age limit based on diagnosis or special healthcare needs. Finally, although the entire document can be a resource for comprehensive program development, each chapter is intended to stand alone and thus support curriculum development specific to the needs of individual programs.
Conclusion and Acknowledgement
The Pediatric Hospital Medicine Core Competencies are intended to provide standards for the knowledge, skills, and attitudes expected of all pediatric hospitalists and to provide a framework for ongoing professional and curriculum development for learners at all levels. We welcome feedback and evaluation from pediatric hospitalists and from all with whom we partner to improve the care for hospitalized children.
We wish to acknowledge the dedication of authors and associate editors, and the thoughtful review by the members of hospital organizations, accrediting bodies, and agencies listed in this supplement. This inaugural edition of the Pediatric Hospital Medicine Core Competenciesshould serve as the foundation from which the field of Pediatric Hospital Medicine will continue to evolve. We look forward with anticipation to future revisions as we reflect on our goals and advance our field.
The Pediatric Hospital Medicine Core Competencies Editorial Board
Erin Stucky, MD
Mary C Ottolini, MD, MPH
Jennifer Maniscalco, MD, MPH
Background
Pediatric Hospital Medicine continues to evolve as an area of specialization, with the refinement of a distinct knowledgebase and skill set focused on the provision of high quality general pediatric care in the inpatient setting. It is the latest site‐specific specialty to emerge from the field of general pediatrics, following a course similar to that charted by pediatric emergency medicine and pediatric critical care medicine in recent decades. The growth of the field has been spurred by a number of factors, including the converging needs for a dedicated emphasis on patient safety, quality improvement, throughput management, and teaching in the inpatient setting.
The number of practicing pediatric hospitalists is estimated to be approximately 2500 and rapidly increasing. To meet the educational needs of this growing cohort of pediatricians, local, regional, and national continuing medical education offerings occur on a regular basis. Furthermore, at least ten fellowships dedicated to advanced training in pediatric hospital medicine have been developed at academic institutions across North America. Despite this, there has been an absence of an accepted and peer‐reviewed framework for professional and curriculum development.
The Pediatric Hospital Medicine Core Competencies represent the first comprehensive attempt to more formally define the standards for the knowledge, skills, attitudes, and focus on systems improvements that are expected of all pediatric hospitalists, regardless of practice setting or location. It is the culmination of more than five years of planning, research, and development by the Society of Hospital Medicine Pediatric Core Curriculum Task Force, leaders within the Academic Pediatric Association and the American Academy of Pediatrics, and the editorial board. The competencies include contributions from over 80 pediatric hospitalists, content experts, and internal and external reviewers representing university and community hospitals, teaching and non‐teaching programs, and key societies and agencies involved in child health from all geographic regions of the United States and Canada. A companion article to Pediatric Hospital Medicine Core Competencies in this Supplement provides additional details regarding the project methodology.
Purpose
The Pediatric Hospital Medicine Core Competencies provide a framework for professional and curriculum development for all pediatric hospitalists. The framework is intended for use by hospital medicine program directors, directors of medical student clerkships, residency programs, fellowships, and continuing medical education, as well as other educators involved in curriculum development. The competencies do not focus on specific content, but rather general learning objectives within the skills, knowledge, and attitudes related to each topic. Attaining competency in the areas defined in these chapters is expected to require post‐residency training. This training is most likely to be obtained through a combination of work experience, local mentorship, and engagement in specific educational programs or fellowship. Pediatric hospitalists, directors, and educators can create specific instructional activities and methods chosen to reflect the characteristics of the intended learners and context of the practice environment.
Organization Structure
The Pediatric Hospital Medicine Core Competencies consist of 54 chapters, divided into four sections Common Clinical Diagnoses and Conditions, Specialized Clinical Services, Core Skills, and Healthcare Systems: Supporting and Advancing Child Health. Within each section, individual chapters on focused topics provide competencies in three domains of educational outcomes: the Cognitive Domain (Knowledge), the Psychomotor Domain (Skills), and the Affective Domain (Attitudes). To reflect the emphasis of hospital medicine practice on improving healthcare systems, a fourth section entitled Systems Organization and Improvement is also included. An attempt has been made to make the objectives timeless, allowing for creation of curriculum that can be nimble and reactive to new discoveries. Highly specific temporal changes in medicine are purposefully excluded, and instead the focus is on the drivers for these changes or advancements. Phrases and wording were selected to help guide the learning activities most likely to achieve each competency and to reflect the varied roles that pediatric hospitalists have in different practice settings. In this document, the terms child and children include infants, children, adolescents, and young adults up to the age of 21, in accordance of policies of the American Academy of Pediatrics. However, it is also understood that care is rendered in pediatric settings for patients who may surpass this upper age limit based on diagnosis or special healthcare needs. Finally, although the entire document can be a resource for comprehensive program development, each chapter is intended to stand alone and thus support curriculum development specific to the needs of individual programs.
Conclusion and Acknowledgement
The Pediatric Hospital Medicine Core Competencies are intended to provide standards for the knowledge, skills, and attitudes expected of all pediatric hospitalists and to provide a framework for ongoing professional and curriculum development for learners at all levels. We welcome feedback and evaluation from pediatric hospitalists and from all with whom we partner to improve the care for hospitalized children.
We wish to acknowledge the dedication of authors and associate editors, and the thoughtful review by the members of hospital organizations, accrediting bodies, and agencies listed in this supplement. This inaugural edition of the Pediatric Hospital Medicine Core Competenciesshould serve as the foundation from which the field of Pediatric Hospital Medicine will continue to evolve. We look forward with anticipation to future revisions as we reflect on our goals and advance our field.
The Pediatric Hospital Medicine Core Competencies Editorial Board
Erin Stucky, MD
Mary C Ottolini, MD, MPH
Jennifer Maniscalco, MD, MPH
Copyright © 2010 Society of Hospital Medicine
Health information systems
Introduction
Health information systems encompass the range of technology in health care used to acquire, store, deliver and analyze medical data. In the hospital environment, this technology is one of the most important components to the delivery of high‐quality and safe care. In particular, healthcare provider order entry, has been shown to reduce medical errors, while systems that display recently completed laboratory testing may decrease redundant testing. Despite these benefits, hospitals have been slow to adopt these technologies. The Institute of Medicine and the Department of Health and Human Services have recognized this fact and have begun serious efforts to improve the adoption of electronic medical information systems in all health care environments. Pediatric hospitalists use these systems for clinical care, education, quality improvement efforts and research and can assist with assessing and implementing systems
Knowledge
Pediatric hospitalists should be able to:
Compare and contrast the varied health information systems used to manage medical information across different hospital settings, especially with regard to the differences between adult and pediatric needs.
Describe the importance of proper storage and retrieval of protected health information.
Discuss the impact of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Rule on health information systems security.
Explain the value of clinical decision support in rendering patient care.
Compare and contrast the influence of electronic health information on practice management, clinical decision‐making, quality improvement projects and performance of research.
Identify at least one improvement in patient safety that can be realized with institution of an electronic medical record.
Describe how hospital policies and procedures impact information systems operations, and that in turn delivery of health care to children influences these policies, procedures, and systems.
Describe the basic organization of the information technology department.
Describe resources that can be accessed to address questions about information systems such as a hospital HELP desk, vendor support lines, or online access to other healthcare providers who use the system.
Delineate how staff dedicated to information technology support quality and safety efforts and data retrieval.
List information resources and tools available to support life‐long learning.
Discuss the importance of pediatric hospitalists in creating, modifying, and evaluating changes to health information systems.
Describe the unique needs of children in regard to information technology, and the importance of careful design and implementation of health information systems in hospitals and clinics that care for children.
Skills
Pediatric hospitalists should be able to:
Demonstrate proficiency with foundational computer skills (email, literature searching, downloading and uploading files.) and common computer applications (word processing, spreadsheet use, and presentation software) as well as the local provider order entry system.
Skillfully access and use web‐based educational resources for continuing education and enrichment of trainee learning experiences.
Effectively and efficiently utilize local health information systems for clinical care, education, and performance of projects as appropriate within the context of the local system.
Assist in creation of order sets and documentation templates.
Assess the value of rules and alerts and assist with editing these as appropriate.
Attitudes
Pediatric hospitalists should be able to:
Be accountable for working to ensure the successful functioning of health information systems.
Advocate for the proper alignment of health information systems choices with clinical needs.
Effectively communicate with information systems managers.
Respect patient confidentiality by using the security‐directed features of information systems.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Participate in appropriate hospital committees and assist with information technology solutions to address causes of unsafe care.
Work with hospital administrators and the Medical Staff to integrate new technologies to the practice of medicine (such as telemedicine, medical decision making, computerized medical records, electronic information networks and others).
Seek opportunities to improve the role of information technology in managing costs, quality improvement efforts, and research, if applicable.
Introduction
Health information systems encompass the range of technology in health care used to acquire, store, deliver and analyze medical data. In the hospital environment, this technology is one of the most important components to the delivery of high‐quality and safe care. In particular, healthcare provider order entry, has been shown to reduce medical errors, while systems that display recently completed laboratory testing may decrease redundant testing. Despite these benefits, hospitals have been slow to adopt these technologies. The Institute of Medicine and the Department of Health and Human Services have recognized this fact and have begun serious efforts to improve the adoption of electronic medical information systems in all health care environments. Pediatric hospitalists use these systems for clinical care, education, quality improvement efforts and research and can assist with assessing and implementing systems
Knowledge
Pediatric hospitalists should be able to:
Compare and contrast the varied health information systems used to manage medical information across different hospital settings, especially with regard to the differences between adult and pediatric needs.
Describe the importance of proper storage and retrieval of protected health information.
Discuss the impact of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Rule on health information systems security.
Explain the value of clinical decision support in rendering patient care.
Compare and contrast the influence of electronic health information on practice management, clinical decision‐making, quality improvement projects and performance of research.
Identify at least one improvement in patient safety that can be realized with institution of an electronic medical record.
Describe how hospital policies and procedures impact information systems operations, and that in turn delivery of health care to children influences these policies, procedures, and systems.
Describe the basic organization of the information technology department.
Describe resources that can be accessed to address questions about information systems such as a hospital HELP desk, vendor support lines, or online access to other healthcare providers who use the system.
Delineate how staff dedicated to information technology support quality and safety efforts and data retrieval.
List information resources and tools available to support life‐long learning.
Discuss the importance of pediatric hospitalists in creating, modifying, and evaluating changes to health information systems.
Describe the unique needs of children in regard to information technology, and the importance of careful design and implementation of health information systems in hospitals and clinics that care for children.
Skills
Pediatric hospitalists should be able to:
Demonstrate proficiency with foundational computer skills (email, literature searching, downloading and uploading files.) and common computer applications (word processing, spreadsheet use, and presentation software) as well as the local provider order entry system.
Skillfully access and use web‐based educational resources for continuing education and enrichment of trainee learning experiences.
Effectively and efficiently utilize local health information systems for clinical care, education, and performance of projects as appropriate within the context of the local system.
Assist in creation of order sets and documentation templates.
Assess the value of rules and alerts and assist with editing these as appropriate.
Attitudes
Pediatric hospitalists should be able to:
Be accountable for working to ensure the successful functioning of health information systems.
Advocate for the proper alignment of health information systems choices with clinical needs.
Effectively communicate with information systems managers.
Respect patient confidentiality by using the security‐directed features of information systems.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Participate in appropriate hospital committees and assist with information technology solutions to address causes of unsafe care.
Work with hospital administrators and the Medical Staff to integrate new technologies to the practice of medicine (such as telemedicine, medical decision making, computerized medical records, electronic information networks and others).
Seek opportunities to improve the role of information technology in managing costs, quality improvement efforts, and research, if applicable.
Introduction
Health information systems encompass the range of technology in health care used to acquire, store, deliver and analyze medical data. In the hospital environment, this technology is one of the most important components to the delivery of high‐quality and safe care. In particular, healthcare provider order entry, has been shown to reduce medical errors, while systems that display recently completed laboratory testing may decrease redundant testing. Despite these benefits, hospitals have been slow to adopt these technologies. The Institute of Medicine and the Department of Health and Human Services have recognized this fact and have begun serious efforts to improve the adoption of electronic medical information systems in all health care environments. Pediatric hospitalists use these systems for clinical care, education, quality improvement efforts and research and can assist with assessing and implementing systems
Knowledge
Pediatric hospitalists should be able to:
Compare and contrast the varied health information systems used to manage medical information across different hospital settings, especially with regard to the differences between adult and pediatric needs.
Describe the importance of proper storage and retrieval of protected health information.
Discuss the impact of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Rule on health information systems security.
Explain the value of clinical decision support in rendering patient care.
Compare and contrast the influence of electronic health information on practice management, clinical decision‐making, quality improvement projects and performance of research.
Identify at least one improvement in patient safety that can be realized with institution of an electronic medical record.
Describe how hospital policies and procedures impact information systems operations, and that in turn delivery of health care to children influences these policies, procedures, and systems.
Describe the basic organization of the information technology department.
Describe resources that can be accessed to address questions about information systems such as a hospital HELP desk, vendor support lines, or online access to other healthcare providers who use the system.
Delineate how staff dedicated to information technology support quality and safety efforts and data retrieval.
List information resources and tools available to support life‐long learning.
Discuss the importance of pediatric hospitalists in creating, modifying, and evaluating changes to health information systems.
Describe the unique needs of children in regard to information technology, and the importance of careful design and implementation of health information systems in hospitals and clinics that care for children.
Skills
Pediatric hospitalists should be able to:
Demonstrate proficiency with foundational computer skills (email, literature searching, downloading and uploading files.) and common computer applications (word processing, spreadsheet use, and presentation software) as well as the local provider order entry system.
Skillfully access and use web‐based educational resources for continuing education and enrichment of trainee learning experiences.
Effectively and efficiently utilize local health information systems for clinical care, education, and performance of projects as appropriate within the context of the local system.
Assist in creation of order sets and documentation templates.
Assess the value of rules and alerts and assist with editing these as appropriate.
Attitudes
Pediatric hospitalists should be able to:
Be accountable for working to ensure the successful functioning of health information systems.
Advocate for the proper alignment of health information systems choices with clinical needs.
Effectively communicate with information systems managers.
Respect patient confidentiality by using the security‐directed features of information systems.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Participate in appropriate hospital committees and assist with information technology solutions to address causes of unsafe care.
Work with hospital administrators and the Medical Staff to integrate new technologies to the practice of medicine (such as telemedicine, medical decision making, computerized medical records, electronic information networks and others).
Seek opportunities to improve the role of information technology in managing costs, quality improvement efforts, and research, if applicable.
Copyright © 2010 Society of Hospital Medicine
Diabetes mellitus
Introduction
Diabetes mellitus, a disorder of glucose homeostasis, is increasing in incidence and prevalence in pediatrics. Although Type 1 diabetes is more frequently diagnosed in children, there has recently been a significant rise in the incidence of Type 2 diabetes, particularly among adolescents in certain ethnic groups. The increasing incidence of Type 2 diabetes parallels the increasing incidence of obesity in the population. In addition to the medical complications associated with this chronic disease, both forms of diabetes have profound social and emotional impacts on the child. Pediatric hospitalists frequently encounter both children with new‐onset diabetes and known diabetics requiring hospitalization because of poor disease control, illness, or elective procedures. Pediatric hospitalists are often in the best position to provide both immediate care for children with diabetes as well as to coordinate care across multiple specialties when necessary.
Knowledge
Pediatric hospitalists should be able to:
Compare and contrast the epidemiology and pathophysiology of Type 1 with Type 2 diabetes attending to differences in impairment of glucose regulation and occurrence of ketoacidosis.
List common alternate causes of hyperglycemia, such as stress, drug, or steroid‐induced hyperglycemia and give examples of situations in which insulin administration is indicated.
Discuss the importance of completing a thorough review of systems and family history and a full physical examination in order to identify polyendocrinopathies.
Describe the role of obesity in the metabolic syndrome and Type 2 diabetes.
List and explain the laboratory tests used to determine the type of diabetes, assess glucose control, and identify complications or co‐morbidities of diabetes (such as glutamic acid decarboxylase, insulin auto antibodies, islet cell antibodies, hemoglobin A1c, thyroid panel, and celiac panel).
Describe the initial management of diabetic ketoacidosis (DKA), attending to fluid delivery, electrolyte monitoring, mental status assessments, frequency of repeated blood testing, and appropriate patient placement based on local facility services.
Define criteria for escalating care in the context of severe acidosis, altered mental status, and effects of electrolyte disturbances.
Summarize the approach toward management and education after stabilization of DKA.
Discuss the importance of including cultural and ethnic practices when creating a diabetes management plan.
Discuss potential complications that may result from treatment, including hypoglycemia and electrolyte imbalances
Identify the co‐morbidities commonly associated with both Type 1 and Type 2 diabetes.
Describe the different formulations of and delivery systems for insulin.
Review the principles of carbohydrate counting.
Discuss short and long‐term prognostic factors associated with complications of poor glucose control.
Skills
Pediatric hospitalists should be able to:
Correctly diagnose diabetes and its complications by efficiently performing an accurate history and physical examination, determining if key features of the disease are present.
Correctly recognize and determine the cause of DKA in the patient with known diabetes by efficiently performing an accurate history and physical examination and ordering appropriate diagnostic tests.
Order appropriate diagnostic testing for patients with new onset diabetes or diabetes exacerbations.
Implement an evidence‐based treatment plan.
Correctly order insulin doses and delivery systems (such as continuous infusion, subcutaneous, and others) and other classes of drugs used in the treatment of diabetes.
Recognize and manage both hyperglycemia and hypoglycemia with particular attention to complications that may arise during treatment.
Recognize the indications for escalating levels of care and promptly initiate appropriate actions.
Identify the indications for in hospital consultation and obtain prompt consultation with an endocrinologist or other subspecialist as appropriate.
Access available support services such as social work, child life, nutrition, and others to ensure a comprehensive management approach.
Clearly articulate discharge criteria and outpatient long term management strategies for patients and the family/caregiver.
Coordinate care and education for patients and the family/caregiver with other healthcare providers.
Coordinate care with subspecialists and the primary care provider and arrange an appropriate transition plan for hospital discharge.
Attitudes
Pediatric hospitalists should be able to:
Communicate effectively with patients maintaining awareness of the unique needs of pre‐adolescent and adolescent age groups.
Discuss the importance of a healthy lifestyle in promoting optimal disease management with patients and the family/caregiver.
Recognize that acute and chronic psychosocial factors impact the ability of patients and the family/caregiver to appropriately manage the disease.
Recognize the importance of the multidisciplinary team approach in the management of diabetes in children, including involvement of the primary care provider, endocrinologist, nutritionist, social worker, psychologist, child life, and school representative.
Maintain awareness of local populations which may have multiple risk factors for diabetes
Collaborate with subspecialists and the primary care provider to ensure coordinated longitudinal care for children with diabetes.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Lead, coordinate or participate in the development and implementation of cost‐effective, safe, evidence‐based care pathways to standardize the evaluation and management for hospitalized children with diabetes.
Work with hospital administration, hospital staff, subspecialists and community organizations to affect system‐wide processes to improve the transition of care from hospital to the ambulatory setting.
Lead, coordinate or participate in system‐wide processes within the hospital to promote therapeutic safety and vigilance in the use of hypoglycemic agents.
Lead, coordinate or participate in educational events to promote awareness of and familiarity with national guidelines for management strategies, new therapeutic and pharmacologic agents and the use of medical devices to improve and monitor glucose homeostasis.
Introduction
Diabetes mellitus, a disorder of glucose homeostasis, is increasing in incidence and prevalence in pediatrics. Although Type 1 diabetes is more frequently diagnosed in children, there has recently been a significant rise in the incidence of Type 2 diabetes, particularly among adolescents in certain ethnic groups. The increasing incidence of Type 2 diabetes parallels the increasing incidence of obesity in the population. In addition to the medical complications associated with this chronic disease, both forms of diabetes have profound social and emotional impacts on the child. Pediatric hospitalists frequently encounter both children with new‐onset diabetes and known diabetics requiring hospitalization because of poor disease control, illness, or elective procedures. Pediatric hospitalists are often in the best position to provide both immediate care for children with diabetes as well as to coordinate care across multiple specialties when necessary.
Knowledge
Pediatric hospitalists should be able to:
Compare and contrast the epidemiology and pathophysiology of Type 1 with Type 2 diabetes attending to differences in impairment of glucose regulation and occurrence of ketoacidosis.
List common alternate causes of hyperglycemia, such as stress, drug, or steroid‐induced hyperglycemia and give examples of situations in which insulin administration is indicated.
Discuss the importance of completing a thorough review of systems and family history and a full physical examination in order to identify polyendocrinopathies.
Describe the role of obesity in the metabolic syndrome and Type 2 diabetes.
List and explain the laboratory tests used to determine the type of diabetes, assess glucose control, and identify complications or co‐morbidities of diabetes (such as glutamic acid decarboxylase, insulin auto antibodies, islet cell antibodies, hemoglobin A1c, thyroid panel, and celiac panel).
Describe the initial management of diabetic ketoacidosis (DKA), attending to fluid delivery, electrolyte monitoring, mental status assessments, frequency of repeated blood testing, and appropriate patient placement based on local facility services.
Define criteria for escalating care in the context of severe acidosis, altered mental status, and effects of electrolyte disturbances.
Summarize the approach toward management and education after stabilization of DKA.
Discuss the importance of including cultural and ethnic practices when creating a diabetes management plan.
Discuss potential complications that may result from treatment, including hypoglycemia and electrolyte imbalances
Identify the co‐morbidities commonly associated with both Type 1 and Type 2 diabetes.
Describe the different formulations of and delivery systems for insulin.
Review the principles of carbohydrate counting.
Discuss short and long‐term prognostic factors associated with complications of poor glucose control.
Skills
Pediatric hospitalists should be able to:
Correctly diagnose diabetes and its complications by efficiently performing an accurate history and physical examination, determining if key features of the disease are present.
Correctly recognize and determine the cause of DKA in the patient with known diabetes by efficiently performing an accurate history and physical examination and ordering appropriate diagnostic tests.
Order appropriate diagnostic testing for patients with new onset diabetes or diabetes exacerbations.
Implement an evidence‐based treatment plan.
Correctly order insulin doses and delivery systems (such as continuous infusion, subcutaneous, and others) and other classes of drugs used in the treatment of diabetes.
Recognize and manage both hyperglycemia and hypoglycemia with particular attention to complications that may arise during treatment.
Recognize the indications for escalating levels of care and promptly initiate appropriate actions.
Identify the indications for in hospital consultation and obtain prompt consultation with an endocrinologist or other subspecialist as appropriate.
Access available support services such as social work, child life, nutrition, and others to ensure a comprehensive management approach.
Clearly articulate discharge criteria and outpatient long term management strategies for patients and the family/caregiver.
Coordinate care and education for patients and the family/caregiver with other healthcare providers.
Coordinate care with subspecialists and the primary care provider and arrange an appropriate transition plan for hospital discharge.
Attitudes
Pediatric hospitalists should be able to:
Communicate effectively with patients maintaining awareness of the unique needs of pre‐adolescent and adolescent age groups.
Discuss the importance of a healthy lifestyle in promoting optimal disease management with patients and the family/caregiver.
Recognize that acute and chronic psychosocial factors impact the ability of patients and the family/caregiver to appropriately manage the disease.
Recognize the importance of the multidisciplinary team approach in the management of diabetes in children, including involvement of the primary care provider, endocrinologist, nutritionist, social worker, psychologist, child life, and school representative.
Maintain awareness of local populations which may have multiple risk factors for diabetes
Collaborate with subspecialists and the primary care provider to ensure coordinated longitudinal care for children with diabetes.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Lead, coordinate or participate in the development and implementation of cost‐effective, safe, evidence‐based care pathways to standardize the evaluation and management for hospitalized children with diabetes.
Work with hospital administration, hospital staff, subspecialists and community organizations to affect system‐wide processes to improve the transition of care from hospital to the ambulatory setting.
Lead, coordinate or participate in system‐wide processes within the hospital to promote therapeutic safety and vigilance in the use of hypoglycemic agents.
Lead, coordinate or participate in educational events to promote awareness of and familiarity with national guidelines for management strategies, new therapeutic and pharmacologic agents and the use of medical devices to improve and monitor glucose homeostasis.
Introduction
Diabetes mellitus, a disorder of glucose homeostasis, is increasing in incidence and prevalence in pediatrics. Although Type 1 diabetes is more frequently diagnosed in children, there has recently been a significant rise in the incidence of Type 2 diabetes, particularly among adolescents in certain ethnic groups. The increasing incidence of Type 2 diabetes parallels the increasing incidence of obesity in the population. In addition to the medical complications associated with this chronic disease, both forms of diabetes have profound social and emotional impacts on the child. Pediatric hospitalists frequently encounter both children with new‐onset diabetes and known diabetics requiring hospitalization because of poor disease control, illness, or elective procedures. Pediatric hospitalists are often in the best position to provide both immediate care for children with diabetes as well as to coordinate care across multiple specialties when necessary.
Knowledge
Pediatric hospitalists should be able to:
Compare and contrast the epidemiology and pathophysiology of Type 1 with Type 2 diabetes attending to differences in impairment of glucose regulation and occurrence of ketoacidosis.
List common alternate causes of hyperglycemia, such as stress, drug, or steroid‐induced hyperglycemia and give examples of situations in which insulin administration is indicated.
Discuss the importance of completing a thorough review of systems and family history and a full physical examination in order to identify polyendocrinopathies.
Describe the role of obesity in the metabolic syndrome and Type 2 diabetes.
List and explain the laboratory tests used to determine the type of diabetes, assess glucose control, and identify complications or co‐morbidities of diabetes (such as glutamic acid decarboxylase, insulin auto antibodies, islet cell antibodies, hemoglobin A1c, thyroid panel, and celiac panel).
Describe the initial management of diabetic ketoacidosis (DKA), attending to fluid delivery, electrolyte monitoring, mental status assessments, frequency of repeated blood testing, and appropriate patient placement based on local facility services.
Define criteria for escalating care in the context of severe acidosis, altered mental status, and effects of electrolyte disturbances.
Summarize the approach toward management and education after stabilization of DKA.
Discuss the importance of including cultural and ethnic practices when creating a diabetes management plan.
Discuss potential complications that may result from treatment, including hypoglycemia and electrolyte imbalances
Identify the co‐morbidities commonly associated with both Type 1 and Type 2 diabetes.
Describe the different formulations of and delivery systems for insulin.
Review the principles of carbohydrate counting.
Discuss short and long‐term prognostic factors associated with complications of poor glucose control.
Skills
Pediatric hospitalists should be able to:
Correctly diagnose diabetes and its complications by efficiently performing an accurate history and physical examination, determining if key features of the disease are present.
Correctly recognize and determine the cause of DKA in the patient with known diabetes by efficiently performing an accurate history and physical examination and ordering appropriate diagnostic tests.
Order appropriate diagnostic testing for patients with new onset diabetes or diabetes exacerbations.
Implement an evidence‐based treatment plan.
Correctly order insulin doses and delivery systems (such as continuous infusion, subcutaneous, and others) and other classes of drugs used in the treatment of diabetes.
Recognize and manage both hyperglycemia and hypoglycemia with particular attention to complications that may arise during treatment.
Recognize the indications for escalating levels of care and promptly initiate appropriate actions.
Identify the indications for in hospital consultation and obtain prompt consultation with an endocrinologist or other subspecialist as appropriate.
Access available support services such as social work, child life, nutrition, and others to ensure a comprehensive management approach.
Clearly articulate discharge criteria and outpatient long term management strategies for patients and the family/caregiver.
Coordinate care and education for patients and the family/caregiver with other healthcare providers.
Coordinate care with subspecialists and the primary care provider and arrange an appropriate transition plan for hospital discharge.
Attitudes
Pediatric hospitalists should be able to:
Communicate effectively with patients maintaining awareness of the unique needs of pre‐adolescent and adolescent age groups.
Discuss the importance of a healthy lifestyle in promoting optimal disease management with patients and the family/caregiver.
Recognize that acute and chronic psychosocial factors impact the ability of patients and the family/caregiver to appropriately manage the disease.
Recognize the importance of the multidisciplinary team approach in the management of diabetes in children, including involvement of the primary care provider, endocrinologist, nutritionist, social worker, psychologist, child life, and school representative.
Maintain awareness of local populations which may have multiple risk factors for diabetes
Collaborate with subspecialists and the primary care provider to ensure coordinated longitudinal care for children with diabetes.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Lead, coordinate or participate in the development and implementation of cost‐effective, safe, evidence‐based care pathways to standardize the evaluation and management for hospitalized children with diabetes.
Work with hospital administration, hospital staff, subspecialists and community organizations to affect system‐wide processes to improve the transition of care from hospital to the ambulatory setting.
Lead, coordinate or participate in system‐wide processes within the hospital to promote therapeutic safety and vigilance in the use of hypoglycemic agents.
Lead, coordinate or participate in educational events to promote awareness of and familiarity with national guidelines for management strategies, new therapeutic and pharmacologic agents and the use of medical devices to improve and monitor glucose homeostasis.
Copyright © 2010 Society of Hospital Medicine
Sickle cell disease
Introduction
Sickle cell disease is the most common autosomal recessive disease in African American individuals. It occurs in 1 in 625 live births to African‐American couples. While it is most common in African Americans, it also occurs in individuals of Hispanic, Arabic, Native American and Caucasian heritage. Sickle cell disease results from a single base‐pair substitution of thymine for adenine resulting in valine instead of glutamine in the sixth position of the Beta‐globin molecule. Sickle cell disease results when this substitution occurs in a homozygous state. Less severe forms occur when the heterozygote state is combined with a second variant Beta‐globin chain such as hemoglobin C or Betao‐thalassemia. Clinical manifestations result from polymerization of the abnormal hemoglobin and sickling of the red cells. The clinical manifestations most important to pediatric hospitalists include recurrent and chronic pain from dactylitis and vaso‐occlusive crises, acute chest syndrome, increased susceptibility to infections, aplastic crisis, splenic sequestration, cerebral vascular accidents and priapism. Pediatric hospitalists commonly encounter patients with known or suspected sickle cell disease and care for the various complications associated with the disease.
Knowledge
Pediatric hospitalists should be able to:
Review the genetics and pathophysiology underlying the variants of sickle cell disease and their complications.
Compare and contrast common sickle crisis presentations by age group.
Explain the impact of newborn screening on preventative care.
Describe the signs and symptoms of dactylitis, vaso‐occlusive crisis, sepsis, acute chest syndrome, aplastic crisis, splenic sequestration, cerebrovascular accidents and priapism.
Describe indications for hospital admission, and escalation to intensive care.
Identify the goals of inpatient therapy, attending to both acute and chronic needs.
Summarize the roles of members of a comprehensive clinical care team, such as patients, family/caregiver, subspecialty physicians, social worker, pharmacist, physical therapist, discharge planner, psychologist and others.
Discuss the therapeutic options available for complications of sickle cell disease and describe the rationale for choosing a specific management plan.
Explain the approach toward acute and chronic pain management.
Cite reasons for transfer to a referral center in cases requiring pediatric‐specific services not available at the local facility.
Skills
Pediatric hospitalists should be able to:
Correctly diagnose sickle cell disease and/or its complications by efficiently performing an accurate history and physical examination, determining if key features of the disease are present.
Order appropriate laboratory and radiographic testing based on history and physical examination findings.
Create a comprehensive evaluation and management plan including the use of antimicrobial therapy, intravenous fluid hydration, pain management, transfusion therapy, and initiation of cardiovascular and pulmonary supportive care measures.
Identify patients with worsening status and respond with appropriate actions.
Consult subspecialists in a timely manner when appropriate.
Attitudes
Pediatric hospitalists should be able to:
Communicate effectively with patients and the family/caregiver regarding the disease process, expectations of inpatient therapy and transition of care to the outpatient arena.
Collaborate with subspecialists and the primary care provider and to ensure coordinated longitudinal care for children with sickle cell disease.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Collaborate with a multidisciplinary team consisting of subspecialty physicians, social workers, pharmacists, physical therapists, discharge planners and psychologists to improve quality of care, increase patient satisfaction and facilitate timely discharge from the acute care setting.
Identify existing limitations for optimal care within the current hospital setting and work with hospital administration and community partners to develop and sustain appropriate referral systems and coordinated transfers of care.
Lead, coordinate or participate in the development of coordinated discharge plans and programs in the local community.
Introduction
Sickle cell disease is the most common autosomal recessive disease in African American individuals. It occurs in 1 in 625 live births to African‐American couples. While it is most common in African Americans, it also occurs in individuals of Hispanic, Arabic, Native American and Caucasian heritage. Sickle cell disease results from a single base‐pair substitution of thymine for adenine resulting in valine instead of glutamine in the sixth position of the Beta‐globin molecule. Sickle cell disease results when this substitution occurs in a homozygous state. Less severe forms occur when the heterozygote state is combined with a second variant Beta‐globin chain such as hemoglobin C or Betao‐thalassemia. Clinical manifestations result from polymerization of the abnormal hemoglobin and sickling of the red cells. The clinical manifestations most important to pediatric hospitalists include recurrent and chronic pain from dactylitis and vaso‐occlusive crises, acute chest syndrome, increased susceptibility to infections, aplastic crisis, splenic sequestration, cerebral vascular accidents and priapism. Pediatric hospitalists commonly encounter patients with known or suspected sickle cell disease and care for the various complications associated with the disease.
Knowledge
Pediatric hospitalists should be able to:
Review the genetics and pathophysiology underlying the variants of sickle cell disease and their complications.
Compare and contrast common sickle crisis presentations by age group.
Explain the impact of newborn screening on preventative care.
Describe the signs and symptoms of dactylitis, vaso‐occlusive crisis, sepsis, acute chest syndrome, aplastic crisis, splenic sequestration, cerebrovascular accidents and priapism.
Describe indications for hospital admission, and escalation to intensive care.
Identify the goals of inpatient therapy, attending to both acute and chronic needs.
Summarize the roles of members of a comprehensive clinical care team, such as patients, family/caregiver, subspecialty physicians, social worker, pharmacist, physical therapist, discharge planner, psychologist and others.
Discuss the therapeutic options available for complications of sickle cell disease and describe the rationale for choosing a specific management plan.
Explain the approach toward acute and chronic pain management.
Cite reasons for transfer to a referral center in cases requiring pediatric‐specific services not available at the local facility.
Skills
Pediatric hospitalists should be able to:
Correctly diagnose sickle cell disease and/or its complications by efficiently performing an accurate history and physical examination, determining if key features of the disease are present.
Order appropriate laboratory and radiographic testing based on history and physical examination findings.
Create a comprehensive evaluation and management plan including the use of antimicrobial therapy, intravenous fluid hydration, pain management, transfusion therapy, and initiation of cardiovascular and pulmonary supportive care measures.
Identify patients with worsening status and respond with appropriate actions.
Consult subspecialists in a timely manner when appropriate.
Attitudes
Pediatric hospitalists should be able to:
Communicate effectively with patients and the family/caregiver regarding the disease process, expectations of inpatient therapy and transition of care to the outpatient arena.
Collaborate with subspecialists and the primary care provider and to ensure coordinated longitudinal care for children with sickle cell disease.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Collaborate with a multidisciplinary team consisting of subspecialty physicians, social workers, pharmacists, physical therapists, discharge planners and psychologists to improve quality of care, increase patient satisfaction and facilitate timely discharge from the acute care setting.
Identify existing limitations for optimal care within the current hospital setting and work with hospital administration and community partners to develop and sustain appropriate referral systems and coordinated transfers of care.
Lead, coordinate or participate in the development of coordinated discharge plans and programs in the local community.
Introduction
Sickle cell disease is the most common autosomal recessive disease in African American individuals. It occurs in 1 in 625 live births to African‐American couples. While it is most common in African Americans, it also occurs in individuals of Hispanic, Arabic, Native American and Caucasian heritage. Sickle cell disease results from a single base‐pair substitution of thymine for adenine resulting in valine instead of glutamine in the sixth position of the Beta‐globin molecule. Sickle cell disease results when this substitution occurs in a homozygous state. Less severe forms occur when the heterozygote state is combined with a second variant Beta‐globin chain such as hemoglobin C or Betao‐thalassemia. Clinical manifestations result from polymerization of the abnormal hemoglobin and sickling of the red cells. The clinical manifestations most important to pediatric hospitalists include recurrent and chronic pain from dactylitis and vaso‐occlusive crises, acute chest syndrome, increased susceptibility to infections, aplastic crisis, splenic sequestration, cerebral vascular accidents and priapism. Pediatric hospitalists commonly encounter patients with known or suspected sickle cell disease and care for the various complications associated with the disease.
Knowledge
Pediatric hospitalists should be able to:
Review the genetics and pathophysiology underlying the variants of sickle cell disease and their complications.
Compare and contrast common sickle crisis presentations by age group.
Explain the impact of newborn screening on preventative care.
Describe the signs and symptoms of dactylitis, vaso‐occlusive crisis, sepsis, acute chest syndrome, aplastic crisis, splenic sequestration, cerebrovascular accidents and priapism.
Describe indications for hospital admission, and escalation to intensive care.
Identify the goals of inpatient therapy, attending to both acute and chronic needs.
Summarize the roles of members of a comprehensive clinical care team, such as patients, family/caregiver, subspecialty physicians, social worker, pharmacist, physical therapist, discharge planner, psychologist and others.
Discuss the therapeutic options available for complications of sickle cell disease and describe the rationale for choosing a specific management plan.
Explain the approach toward acute and chronic pain management.
Cite reasons for transfer to a referral center in cases requiring pediatric‐specific services not available at the local facility.
Skills
Pediatric hospitalists should be able to:
Correctly diagnose sickle cell disease and/or its complications by efficiently performing an accurate history and physical examination, determining if key features of the disease are present.
Order appropriate laboratory and radiographic testing based on history and physical examination findings.
Create a comprehensive evaluation and management plan including the use of antimicrobial therapy, intravenous fluid hydration, pain management, transfusion therapy, and initiation of cardiovascular and pulmonary supportive care measures.
Identify patients with worsening status and respond with appropriate actions.
Consult subspecialists in a timely manner when appropriate.
Attitudes
Pediatric hospitalists should be able to:
Communicate effectively with patients and the family/caregiver regarding the disease process, expectations of inpatient therapy and transition of care to the outpatient arena.
Collaborate with subspecialists and the primary care provider and to ensure coordinated longitudinal care for children with sickle cell disease.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Collaborate with a multidisciplinary team consisting of subspecialty physicians, social workers, pharmacists, physical therapists, discharge planners and psychologists to improve quality of care, increase patient satisfaction and facilitate timely discharge from the acute care setting.
Identify existing limitations for optimal care within the current hospital setting and work with hospital administration and community partners to develop and sustain appropriate referral systems and coordinated transfers of care.
Lead, coordinate or participate in the development of coordinated discharge plans and programs in the local community.
Copyright © 2010 Society of Hospital Medicine
Procedural sedation
Introduction
Sedation is often used to minimize procedure related pain and to provide decreased motion for diagnostic studies. Control of pain, anxiety and memory may minimize negative psychological responses to treatment and also lead to a higher success rate for the therapy or diagnostic test. Safe attainment of these goals requires careful preparation and decision‐making prior to the procedure, meticulous monitoring during the procedure, and application of skills to avoid or treat the complications of sedation including ability to rescue patients from a deeper level of sedation than intended. With appropriate training and experience, pediatric hospitalists can safely provide a range of sedation services for pediatric patients.
Knowledge
Pediatric hospitalists should be able to:
Describe the goals of sedation, such as pain control, anxiolysis, amnesia, and motion control.
List commonly used single or combinations of medications, and describe how each achieves the desired goal with the minimum risk of complications and side effects.
Compare and contrast the goals of isolated anxiolysis with minimal sedation, attending to issues such as medication choice and dosing, procedure, and patient past procedural history.
Define minimal sedation, moderate sedation, deep sedation, and general anesthesia as established by the American Society of Anesthesiologists (ASA), American Academy of Pediatrics (AAP), and The Joint Commission (TJC).
Discuss the pharmacology and effects of commonly used sedation medications, including planned effects and potential side effects.
Explain why non‐pharmacologic interventions such as bundling, glucose water pacifiers, family/caregiver presence, visual imagery, deep breathing, music and others are important adjuncts to medication use in mitigating the perception of pain and anxiety.
Explain the risks inherent with administration of sedating medications, and list the proper monitoring necessary to avoid or promptly recognize instability.
Describe how age, disease process, and anatomy may increase the risk of sedation complications.
Discuss the proper level of monitoring personnel necessary to maximize safety.
Review indications for use of common reversal drugs, including anticipated results and duration of rescue effects.
Skills
Pediatric hospitalists should be able to:
Perform a pre‐sedation evaluation and appropriately assign ASA class and delineate patient‐specific risks.
Correctly recognize patients at higher risk and efficiently refer to an anesthesiologist.
Correctly obtain informed consent from the family/caregiver.
Develop a sedation plan that is based on the pre‐sedation evaluation and considers goals for the sedation and risks to patients.
Communicate effectively with the healthcare team before, during, and after the sedation to ensure that safe and efficient care is rendered.
Identify complications and respond with appropriate actions.
Manage the airway and provide pediatric advanced life support in case of known or unexpected complications.
Order appropriate monitoring and correctly interpret monitor data.
Identify when recovery criteria are met, and initiate an appropriate discharge/transfer plan.
Attitudes
Pediatric hospitalists should be able to:
Work collaboratively with hospital staff and subspecialists to ensure coordinated planning and performance of sedation.
Communicate effectively with patients and the family/caregiver regarding the indications for, risks, benefits, and steps of sedation.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Lead, coordinate or participate in the development and implementation of cost‐effective, safe, evidence‐based procedures and policies for performance of sedation for children.
Lead, coordinate or participate in the development and implementation of a system for review of family/caregiver and healthcare provider satisfaction into procedural strategies.
Work with hospital staff and subspecialists to develop and implement management strategies for sedation.
Lead, coordinate or participate in the development and implementation of a system for review of the efficacy, efficiency and outcomes of intravenous access procedures.
Lead, coordinate or participate in the development and implementation of a system for review of the efficacy, efficiency and outcomes of sedation procedures.
Introduction
Sedation is often used to minimize procedure related pain and to provide decreased motion for diagnostic studies. Control of pain, anxiety and memory may minimize negative psychological responses to treatment and also lead to a higher success rate for the therapy or diagnostic test. Safe attainment of these goals requires careful preparation and decision‐making prior to the procedure, meticulous monitoring during the procedure, and application of skills to avoid or treat the complications of sedation including ability to rescue patients from a deeper level of sedation than intended. With appropriate training and experience, pediatric hospitalists can safely provide a range of sedation services for pediatric patients.
Knowledge
Pediatric hospitalists should be able to:
Describe the goals of sedation, such as pain control, anxiolysis, amnesia, and motion control.
List commonly used single or combinations of medications, and describe how each achieves the desired goal with the minimum risk of complications and side effects.
Compare and contrast the goals of isolated anxiolysis with minimal sedation, attending to issues such as medication choice and dosing, procedure, and patient past procedural history.
Define minimal sedation, moderate sedation, deep sedation, and general anesthesia as established by the American Society of Anesthesiologists (ASA), American Academy of Pediatrics (AAP), and The Joint Commission (TJC).
Discuss the pharmacology and effects of commonly used sedation medications, including planned effects and potential side effects.
Explain why non‐pharmacologic interventions such as bundling, glucose water pacifiers, family/caregiver presence, visual imagery, deep breathing, music and others are important adjuncts to medication use in mitigating the perception of pain and anxiety.
Explain the risks inherent with administration of sedating medications, and list the proper monitoring necessary to avoid or promptly recognize instability.
Describe how age, disease process, and anatomy may increase the risk of sedation complications.
Discuss the proper level of monitoring personnel necessary to maximize safety.
Review indications for use of common reversal drugs, including anticipated results and duration of rescue effects.
Skills
Pediatric hospitalists should be able to:
Perform a pre‐sedation evaluation and appropriately assign ASA class and delineate patient‐specific risks.
Correctly recognize patients at higher risk and efficiently refer to an anesthesiologist.
Correctly obtain informed consent from the family/caregiver.
Develop a sedation plan that is based on the pre‐sedation evaluation and considers goals for the sedation and risks to patients.
Communicate effectively with the healthcare team before, during, and after the sedation to ensure that safe and efficient care is rendered.
Identify complications and respond with appropriate actions.
Manage the airway and provide pediatric advanced life support in case of known or unexpected complications.
Order appropriate monitoring and correctly interpret monitor data.
Identify when recovery criteria are met, and initiate an appropriate discharge/transfer plan.
Attitudes
Pediatric hospitalists should be able to:
Work collaboratively with hospital staff and subspecialists to ensure coordinated planning and performance of sedation.
Communicate effectively with patients and the family/caregiver regarding the indications for, risks, benefits, and steps of sedation.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Lead, coordinate or participate in the development and implementation of cost‐effective, safe, evidence‐based procedures and policies for performance of sedation for children.
Lead, coordinate or participate in the development and implementation of a system for review of family/caregiver and healthcare provider satisfaction into procedural strategies.
Work with hospital staff and subspecialists to develop and implement management strategies for sedation.
Lead, coordinate or participate in the development and implementation of a system for review of the efficacy, efficiency and outcomes of intravenous access procedures.
Lead, coordinate or participate in the development and implementation of a system for review of the efficacy, efficiency and outcomes of sedation procedures.
Introduction
Sedation is often used to minimize procedure related pain and to provide decreased motion for diagnostic studies. Control of pain, anxiety and memory may minimize negative psychological responses to treatment and also lead to a higher success rate for the therapy or diagnostic test. Safe attainment of these goals requires careful preparation and decision‐making prior to the procedure, meticulous monitoring during the procedure, and application of skills to avoid or treat the complications of sedation including ability to rescue patients from a deeper level of sedation than intended. With appropriate training and experience, pediatric hospitalists can safely provide a range of sedation services for pediatric patients.
Knowledge
Pediatric hospitalists should be able to:
Describe the goals of sedation, such as pain control, anxiolysis, amnesia, and motion control.
List commonly used single or combinations of medications, and describe how each achieves the desired goal with the minimum risk of complications and side effects.
Compare and contrast the goals of isolated anxiolysis with minimal sedation, attending to issues such as medication choice and dosing, procedure, and patient past procedural history.
Define minimal sedation, moderate sedation, deep sedation, and general anesthesia as established by the American Society of Anesthesiologists (ASA), American Academy of Pediatrics (AAP), and The Joint Commission (TJC).
Discuss the pharmacology and effects of commonly used sedation medications, including planned effects and potential side effects.
Explain why non‐pharmacologic interventions such as bundling, glucose water pacifiers, family/caregiver presence, visual imagery, deep breathing, music and others are important adjuncts to medication use in mitigating the perception of pain and anxiety.
Explain the risks inherent with administration of sedating medications, and list the proper monitoring necessary to avoid or promptly recognize instability.
Describe how age, disease process, and anatomy may increase the risk of sedation complications.
Discuss the proper level of monitoring personnel necessary to maximize safety.
Review indications for use of common reversal drugs, including anticipated results and duration of rescue effects.
Skills
Pediatric hospitalists should be able to:
Perform a pre‐sedation evaluation and appropriately assign ASA class and delineate patient‐specific risks.
Correctly recognize patients at higher risk and efficiently refer to an anesthesiologist.
Correctly obtain informed consent from the family/caregiver.
Develop a sedation plan that is based on the pre‐sedation evaluation and considers goals for the sedation and risks to patients.
Communicate effectively with the healthcare team before, during, and after the sedation to ensure that safe and efficient care is rendered.
Identify complications and respond with appropriate actions.
Manage the airway and provide pediatric advanced life support in case of known or unexpected complications.
Order appropriate monitoring and correctly interpret monitor data.
Identify when recovery criteria are met, and initiate an appropriate discharge/transfer plan.
Attitudes
Pediatric hospitalists should be able to:
Work collaboratively with hospital staff and subspecialists to ensure coordinated planning and performance of sedation.
Communicate effectively with patients and the family/caregiver regarding the indications for, risks, benefits, and steps of sedation.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Lead, coordinate or participate in the development and implementation of cost‐effective, safe, evidence‐based procedures and policies for performance of sedation for children.
Lead, coordinate or participate in the development and implementation of a system for review of family/caregiver and healthcare provider satisfaction into procedural strategies.
Work with hospital staff and subspecialists to develop and implement management strategies for sedation.
Lead, coordinate or participate in the development and implementation of a system for review of the efficacy, efficiency and outcomes of intravenous access procedures.
Lead, coordinate or participate in the development and implementation of a system for review of the efficacy, efficiency and outcomes of sedation procedures.
Copyright © 2010 Society of Hospital Medicine
Pain management
Introduction
Acute pain (pain) is a common complaint in the pediatric inpatient setting and is most often associated with exacerbations of chronic diseases, trauma, burns or surgical and diagnostic procedures. Children with acute pain may also have chronic pain due to an underlying illness or previous injury. Chronic pain complicates effective control of acute pain and may be associated with neuropsychological changes that impact pain perception. Despite advances in understanding of the pathophysiology and management of pain in children, several barriers to effective pain management exist, such as fear of harmful side effects and drug dependency. Pediatric hospitalists should enhance pain management services through the direct provision of effective care, and are often in the best position to lead development of a systematic approach to pain management in institutions and communities.
Knowledge
Pediatric hospitalists should be able to:
Describe the pathophysiology and multidimensional aspects of pain in children of various ages.
Explain how pain, anxiety, and fear interrelate and discuss strategies for addressing each.
List the indications and contraindications for the main classes of drugs used for pain management, such as opioids, non‐steroidal anti‐inflammatory drugs, and topical and local anesthetics.
Discuss the pharmacology of medications commonly used for analgesia, including route of administration, dosing range, and expected side effects.
Discuss the pharmacology of medications used for anxiolysis, including route of administration, dosing range, and expected side effects.
Describe the effects of age, anatomy, and disease process on the pharmacology of medications used for analgesia and anxiolysis.
Compare and contrast the risks and benefits of various modalities of drug delivery attending to drug delivery, side effects, and invasiveness and safety of delivery methods/devices.
List appropriate monitoring techniques for patients receiving analgesics, anxiolytics, and other associated medications.
Describe the pharmacology of and indications for reversal agents for specific classes of drugs used for pain management.
Discuss how use of adjuvant medications, such as antidepressants, anticonvulsants, anxiolytics, and sleep medications can be used most appropriately for pain management.
Discuss how complementary techniques such as behavioral therapy, play therapy, and physical therapy can be utilized to manage pain and anxiety.
Describe the role of the pediatric pain consultant/pain management team and discuss barriers to local availability.
Skills
Pediatric hospitalists should be able to:
Accurately assess the presence and level of pain in children regardless of developmental level utilizing history, physical examination, physiologic parameters, and validated pediatric pain scales.
Appropriately prescribe doses of analgesic medication that ameliorate pain while avoiding untoward side effects.
Demonstrate proficiency in adjusting drug doses in the face of breakthrough pain.
Safely prescribe equi‐analgesic doses or adjust doses appropriately when changing from intravenous to oral therapy or when switching from one medication to another.
Select and order pain and anxiety medications in safe and cost‐effective manner.
Correctly calculate and order a pain and anxiolytic medication tapering regimen that avoids withdrawal symptoms or breakthrough pain.
Perform careful reassessments daily and as needed, note changes in clinical status, pain, side effects, and withdrawal symptoms and respond with appropriate actions.
Order appropriate monitoring and correctly interpret monitor data.
Anticipate and recognize potential side effects of analgesic and anxiolytic medications and respond with appropriate actions.
Consistently utilize non‐pharmacologic methods as part of a pain management plan.
Identify patients likely to have chronic pain, and involve appropriate consultants to assist with long term management.
Identify patients with neuropathic pain and develop a treatment plan with assistance from appropriate consultants.
Correctly identify discharge needs and create a comprehensive discharge plan attending to equipment, medications, and specialty services required.
Attitudes
Pediatric hospitalists should be able to:
Educate patients and the family/caregiver on various aspects of pain, including etiologies, management, and impact on the healing process.
Involve the primary care provider in the therapeutic process early in the hospitalization and work together to coordinate appropriate follow‐up care.
Recognize the impact of uncontrolled pain has on patients' emotional and physical well‐being.
Collaborate with subspecialists and the primary care provider to ensure coordinated longitudinal care for children receiving chronic pain management services.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Work with hospital administration, hospital staff, subspecialists and others to implement a comprehensive, systematic approach to pain management across the continuum of care.
Lead, coordinate or participate in the development and implementation of cost‐effective, safe, evidence‐based care to standardize the evaluation and management for hospitalized children with pain.
Educate other healthcare providers who may work with children on pediatric pain assessment and safe medication use.
Work in consultation with surgical staff to prioritize and improve the management of pain in pediatric surgical patients.
Introduction
Acute pain (pain) is a common complaint in the pediatric inpatient setting and is most often associated with exacerbations of chronic diseases, trauma, burns or surgical and diagnostic procedures. Children with acute pain may also have chronic pain due to an underlying illness or previous injury. Chronic pain complicates effective control of acute pain and may be associated with neuropsychological changes that impact pain perception. Despite advances in understanding of the pathophysiology and management of pain in children, several barriers to effective pain management exist, such as fear of harmful side effects and drug dependency. Pediatric hospitalists should enhance pain management services through the direct provision of effective care, and are often in the best position to lead development of a systematic approach to pain management in institutions and communities.
Knowledge
Pediatric hospitalists should be able to:
Describe the pathophysiology and multidimensional aspects of pain in children of various ages.
Explain how pain, anxiety, and fear interrelate and discuss strategies for addressing each.
List the indications and contraindications for the main classes of drugs used for pain management, such as opioids, non‐steroidal anti‐inflammatory drugs, and topical and local anesthetics.
Discuss the pharmacology of medications commonly used for analgesia, including route of administration, dosing range, and expected side effects.
Discuss the pharmacology of medications used for anxiolysis, including route of administration, dosing range, and expected side effects.
Describe the effects of age, anatomy, and disease process on the pharmacology of medications used for analgesia and anxiolysis.
Compare and contrast the risks and benefits of various modalities of drug delivery attending to drug delivery, side effects, and invasiveness and safety of delivery methods/devices.
List appropriate monitoring techniques for patients receiving analgesics, anxiolytics, and other associated medications.
Describe the pharmacology of and indications for reversal agents for specific classes of drugs used for pain management.
Discuss how use of adjuvant medications, such as antidepressants, anticonvulsants, anxiolytics, and sleep medications can be used most appropriately for pain management.
Discuss how complementary techniques such as behavioral therapy, play therapy, and physical therapy can be utilized to manage pain and anxiety.
Describe the role of the pediatric pain consultant/pain management team and discuss barriers to local availability.
Skills
Pediatric hospitalists should be able to:
Accurately assess the presence and level of pain in children regardless of developmental level utilizing history, physical examination, physiologic parameters, and validated pediatric pain scales.
Appropriately prescribe doses of analgesic medication that ameliorate pain while avoiding untoward side effects.
Demonstrate proficiency in adjusting drug doses in the face of breakthrough pain.
Safely prescribe equi‐analgesic doses or adjust doses appropriately when changing from intravenous to oral therapy or when switching from one medication to another.
Select and order pain and anxiety medications in safe and cost‐effective manner.
Correctly calculate and order a pain and anxiolytic medication tapering regimen that avoids withdrawal symptoms or breakthrough pain.
Perform careful reassessments daily and as needed, note changes in clinical status, pain, side effects, and withdrawal symptoms and respond with appropriate actions.
Order appropriate monitoring and correctly interpret monitor data.
Anticipate and recognize potential side effects of analgesic and anxiolytic medications and respond with appropriate actions.
Consistently utilize non‐pharmacologic methods as part of a pain management plan.
Identify patients likely to have chronic pain, and involve appropriate consultants to assist with long term management.
Identify patients with neuropathic pain and develop a treatment plan with assistance from appropriate consultants.
Correctly identify discharge needs and create a comprehensive discharge plan attending to equipment, medications, and specialty services required.
Attitudes
Pediatric hospitalists should be able to:
Educate patients and the family/caregiver on various aspects of pain, including etiologies, management, and impact on the healing process.
Involve the primary care provider in the therapeutic process early in the hospitalization and work together to coordinate appropriate follow‐up care.
Recognize the impact of uncontrolled pain has on patients' emotional and physical well‐being.
Collaborate with subspecialists and the primary care provider to ensure coordinated longitudinal care for children receiving chronic pain management services.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Work with hospital administration, hospital staff, subspecialists and others to implement a comprehensive, systematic approach to pain management across the continuum of care.
Lead, coordinate or participate in the development and implementation of cost‐effective, safe, evidence‐based care to standardize the evaluation and management for hospitalized children with pain.
Educate other healthcare providers who may work with children on pediatric pain assessment and safe medication use.
Work in consultation with surgical staff to prioritize and improve the management of pain in pediatric surgical patients.
Introduction
Acute pain (pain) is a common complaint in the pediatric inpatient setting and is most often associated with exacerbations of chronic diseases, trauma, burns or surgical and diagnostic procedures. Children with acute pain may also have chronic pain due to an underlying illness or previous injury. Chronic pain complicates effective control of acute pain and may be associated with neuropsychological changes that impact pain perception. Despite advances in understanding of the pathophysiology and management of pain in children, several barriers to effective pain management exist, such as fear of harmful side effects and drug dependency. Pediatric hospitalists should enhance pain management services through the direct provision of effective care, and are often in the best position to lead development of a systematic approach to pain management in institutions and communities.
Knowledge
Pediatric hospitalists should be able to:
Describe the pathophysiology and multidimensional aspects of pain in children of various ages.
Explain how pain, anxiety, and fear interrelate and discuss strategies for addressing each.
List the indications and contraindications for the main classes of drugs used for pain management, such as opioids, non‐steroidal anti‐inflammatory drugs, and topical and local anesthetics.
Discuss the pharmacology of medications commonly used for analgesia, including route of administration, dosing range, and expected side effects.
Discuss the pharmacology of medications used for anxiolysis, including route of administration, dosing range, and expected side effects.
Describe the effects of age, anatomy, and disease process on the pharmacology of medications used for analgesia and anxiolysis.
Compare and contrast the risks and benefits of various modalities of drug delivery attending to drug delivery, side effects, and invasiveness and safety of delivery methods/devices.
List appropriate monitoring techniques for patients receiving analgesics, anxiolytics, and other associated medications.
Describe the pharmacology of and indications for reversal agents for specific classes of drugs used for pain management.
Discuss how use of adjuvant medications, such as antidepressants, anticonvulsants, anxiolytics, and sleep medications can be used most appropriately for pain management.
Discuss how complementary techniques such as behavioral therapy, play therapy, and physical therapy can be utilized to manage pain and anxiety.
Describe the role of the pediatric pain consultant/pain management team and discuss barriers to local availability.
Skills
Pediatric hospitalists should be able to:
Accurately assess the presence and level of pain in children regardless of developmental level utilizing history, physical examination, physiologic parameters, and validated pediatric pain scales.
Appropriately prescribe doses of analgesic medication that ameliorate pain while avoiding untoward side effects.
Demonstrate proficiency in adjusting drug doses in the face of breakthrough pain.
Safely prescribe equi‐analgesic doses or adjust doses appropriately when changing from intravenous to oral therapy or when switching from one medication to another.
Select and order pain and anxiety medications in safe and cost‐effective manner.
Correctly calculate and order a pain and anxiolytic medication tapering regimen that avoids withdrawal symptoms or breakthrough pain.
Perform careful reassessments daily and as needed, note changes in clinical status, pain, side effects, and withdrawal symptoms and respond with appropriate actions.
Order appropriate monitoring and correctly interpret monitor data.
Anticipate and recognize potential side effects of analgesic and anxiolytic medications and respond with appropriate actions.
Consistently utilize non‐pharmacologic methods as part of a pain management plan.
Identify patients likely to have chronic pain, and involve appropriate consultants to assist with long term management.
Identify patients with neuropathic pain and develop a treatment plan with assistance from appropriate consultants.
Correctly identify discharge needs and create a comprehensive discharge plan attending to equipment, medications, and specialty services required.
Attitudes
Pediatric hospitalists should be able to:
Educate patients and the family/caregiver on various aspects of pain, including etiologies, management, and impact on the healing process.
Involve the primary care provider in the therapeutic process early in the hospitalization and work together to coordinate appropriate follow‐up care.
Recognize the impact of uncontrolled pain has on patients' emotional and physical well‐being.
Collaborate with subspecialists and the primary care provider to ensure coordinated longitudinal care for children receiving chronic pain management services.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Work with hospital administration, hospital staff, subspecialists and others to implement a comprehensive, systematic approach to pain management across the continuum of care.
Lead, coordinate or participate in the development and implementation of cost‐effective, safe, evidence‐based care to standardize the evaluation and management for hospitalized children with pain.
Educate other healthcare providers who may work with children on pediatric pain assessment and safe medication use.
Work in consultation with surgical staff to prioritize and improve the management of pain in pediatric surgical patients.
Copyright © 2010 Society of Hospital Medicine
Acute abdominal pain and the acute abdomen
Introduction
Acute abdominal pain is a common presenting symptom of children and adolescents and prompts the consideration of an extensive differential diagnosis. Although it is frequently due to common, self‐limited medical conditions related to the abdomen such as gastroenteritis, it may also be a signal of systemic illness or referred from problems elsewhere in the body. Acute abdominal pain may or may not be accompanied by signs and symptoms of an acute abdomen such as loss of bowel sounds or evidence of obstruction. Identifying children with a true medical or surgical emergency is critical. Children with peritonitis and other surgical conditions need prompt evaluation by a surgeon with pediatric expertise. Early diagnosis and treatment reduces morbidity, mortality, and length of hospital stay. Pediatric hospitalists frequently encounter children with acute abdominal pain in a variety of clinical settings and should assist in the timely and effective evaluation and management either alone or in conjunction with a surgeon.
Knowledge
Pediatric hospitalists should be able to:
Recognize features of the medical history and physical examination that prompt specific diagnostic evaluation.
Describe the differential diagnosis of acute abdominal pain as well the acute abdomen for children of varying chronological and developmental ages.
List gender‐specific etiologies of acute abdominal pain, such as testicular torsion and ovarian cyst rupture.
Identify the role congenital anomalies may play in the child with an acute abdomen.
Discuss the principles of stabilization of the child with an acute abdomen, such as volume resuscitation, antibiotics, and bowel decompression.
List conditions that may mimic the acute abdomen, such as lower lobe pneumonia and diabetic ketoacidosis.
State the importance of, and indications for, early surgical consultation in the child with an acute abdomen.
Compare and contrast benefits versus limitations of various commonly performed studies such as acute abdominal series, sonography, computed tomography, nuclear medicine scans, and magnetic resonance imaging. State the benefits of and barriers to use of contrast enhancement for these studies.
Provide indications for hospital admission and cite the reasons for admission to various locations in the hospital system, such as a short‐stay unit, surgical or medical ward, step‐down intensive care unit, or intensive care unit.
Cite reasons for patient transfer to a referral center in cases requiring pediatric‐specific services not available at the local facility.
Identify specific evaluation and treatment needs for technology dependent children who present with an acute abdomen, including children with feeding and drainage tubes (gastrostomy, jejunostomy, ileosotomy, and others), long term vascular access devices (ports, Hickman catheters, and others), shunts (ventricular, other), ventilator dependence, and other implanted devices.
Summarize the approach toward pain control in patients presenting with acute abdominal pain, attending to medication choice, delivery method, and impact on exam re‐assessments.
Skills
Pediatric hospitalists should be able to:
Obtain an accurate history and perform a thorough physical examination.
Formulate a targeted differential diagnosis based on elements from the history and physical examination, prior to ordering studies.
Identify the child with an acute abdomen.
Identify and manage the child with concomitant hypovolemia or sepsis.
Direct an appropriate and cost‐effective evaluation to identify the cause of the abdominal pain or the acute abdomen.
Access radiology services efficiently, for both performance and interpretation of studies.
Order and correctly interpret commonly performed basic diagnostic imaging studies and laboratory studies.
Consult surgeons effectively and efficiently when indicated.
Identify the child requiring emergent surgical consultation.
Provide pre‐ and post‐operative general pediatric care for the child requiring surgery, as appropriate, including pain management.
Coordinate care with the primary care provider and arrange an appropriate transition plan for hospital discharge.
Attitudes
Pediatric hospitalists should be able to:
Assume responsibility for care of patients as the primary attending or in collaboration with the surgical team.
Communicate effectively with patients, the family/caregiver, and healthcare providers regarding findings and care plans.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Educate healthcare providers, trainees, the family/caregiver regarding the signs and symptoms of the acute abdomen to encourage early detection and prompt evaluation.
Lead, coordinate or participate in a multidisciplinary team to provide optimal care for children with acute abdominal pain with and without acute abdomen.
Incorporate knowledge of outcomes research and cost management strategies into the evaluation and treatment of patients with an acute abdomen.
Lead, coordinate or participate in institutional efforts to improve the expediency of diagnostic laboratory and radiographic studies, availability of specialty care, and other resources for patients with acute abdominal pain and acute abdomen.
Introduction
Acute abdominal pain is a common presenting symptom of children and adolescents and prompts the consideration of an extensive differential diagnosis. Although it is frequently due to common, self‐limited medical conditions related to the abdomen such as gastroenteritis, it may also be a signal of systemic illness or referred from problems elsewhere in the body. Acute abdominal pain may or may not be accompanied by signs and symptoms of an acute abdomen such as loss of bowel sounds or evidence of obstruction. Identifying children with a true medical or surgical emergency is critical. Children with peritonitis and other surgical conditions need prompt evaluation by a surgeon with pediatric expertise. Early diagnosis and treatment reduces morbidity, mortality, and length of hospital stay. Pediatric hospitalists frequently encounter children with acute abdominal pain in a variety of clinical settings and should assist in the timely and effective evaluation and management either alone or in conjunction with a surgeon.
Knowledge
Pediatric hospitalists should be able to:
Recognize features of the medical history and physical examination that prompt specific diagnostic evaluation.
Describe the differential diagnosis of acute abdominal pain as well the acute abdomen for children of varying chronological and developmental ages.
List gender‐specific etiologies of acute abdominal pain, such as testicular torsion and ovarian cyst rupture.
Identify the role congenital anomalies may play in the child with an acute abdomen.
Discuss the principles of stabilization of the child with an acute abdomen, such as volume resuscitation, antibiotics, and bowel decompression.
List conditions that may mimic the acute abdomen, such as lower lobe pneumonia and diabetic ketoacidosis.
State the importance of, and indications for, early surgical consultation in the child with an acute abdomen.
Compare and contrast benefits versus limitations of various commonly performed studies such as acute abdominal series, sonography, computed tomography, nuclear medicine scans, and magnetic resonance imaging. State the benefits of and barriers to use of contrast enhancement for these studies.
Provide indications for hospital admission and cite the reasons for admission to various locations in the hospital system, such as a short‐stay unit, surgical or medical ward, step‐down intensive care unit, or intensive care unit.
Cite reasons for patient transfer to a referral center in cases requiring pediatric‐specific services not available at the local facility.
Identify specific evaluation and treatment needs for technology dependent children who present with an acute abdomen, including children with feeding and drainage tubes (gastrostomy, jejunostomy, ileosotomy, and others), long term vascular access devices (ports, Hickman catheters, and others), shunts (ventricular, other), ventilator dependence, and other implanted devices.
Summarize the approach toward pain control in patients presenting with acute abdominal pain, attending to medication choice, delivery method, and impact on exam re‐assessments.
Skills
Pediatric hospitalists should be able to:
Obtain an accurate history and perform a thorough physical examination.
Formulate a targeted differential diagnosis based on elements from the history and physical examination, prior to ordering studies.
Identify the child with an acute abdomen.
Identify and manage the child with concomitant hypovolemia or sepsis.
Direct an appropriate and cost‐effective evaluation to identify the cause of the abdominal pain or the acute abdomen.
Access radiology services efficiently, for both performance and interpretation of studies.
Order and correctly interpret commonly performed basic diagnostic imaging studies and laboratory studies.
Consult surgeons effectively and efficiently when indicated.
Identify the child requiring emergent surgical consultation.
Provide pre‐ and post‐operative general pediatric care for the child requiring surgery, as appropriate, including pain management.
Coordinate care with the primary care provider and arrange an appropriate transition plan for hospital discharge.
Attitudes
Pediatric hospitalists should be able to:
Assume responsibility for care of patients as the primary attending or in collaboration with the surgical team.
Communicate effectively with patients, the family/caregiver, and healthcare providers regarding findings and care plans.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Educate healthcare providers, trainees, the family/caregiver regarding the signs and symptoms of the acute abdomen to encourage early detection and prompt evaluation.
Lead, coordinate or participate in a multidisciplinary team to provide optimal care for children with acute abdominal pain with and without acute abdomen.
Incorporate knowledge of outcomes research and cost management strategies into the evaluation and treatment of patients with an acute abdomen.
Lead, coordinate or participate in institutional efforts to improve the expediency of diagnostic laboratory and radiographic studies, availability of specialty care, and other resources for patients with acute abdominal pain and acute abdomen.
Introduction
Acute abdominal pain is a common presenting symptom of children and adolescents and prompts the consideration of an extensive differential diagnosis. Although it is frequently due to common, self‐limited medical conditions related to the abdomen such as gastroenteritis, it may also be a signal of systemic illness or referred from problems elsewhere in the body. Acute abdominal pain may or may not be accompanied by signs and symptoms of an acute abdomen such as loss of bowel sounds or evidence of obstruction. Identifying children with a true medical or surgical emergency is critical. Children with peritonitis and other surgical conditions need prompt evaluation by a surgeon with pediatric expertise. Early diagnosis and treatment reduces morbidity, mortality, and length of hospital stay. Pediatric hospitalists frequently encounter children with acute abdominal pain in a variety of clinical settings and should assist in the timely and effective evaluation and management either alone or in conjunction with a surgeon.
Knowledge
Pediatric hospitalists should be able to:
Recognize features of the medical history and physical examination that prompt specific diagnostic evaluation.
Describe the differential diagnosis of acute abdominal pain as well the acute abdomen for children of varying chronological and developmental ages.
List gender‐specific etiologies of acute abdominal pain, such as testicular torsion and ovarian cyst rupture.
Identify the role congenital anomalies may play in the child with an acute abdomen.
Discuss the principles of stabilization of the child with an acute abdomen, such as volume resuscitation, antibiotics, and bowel decompression.
List conditions that may mimic the acute abdomen, such as lower lobe pneumonia and diabetic ketoacidosis.
State the importance of, and indications for, early surgical consultation in the child with an acute abdomen.
Compare and contrast benefits versus limitations of various commonly performed studies such as acute abdominal series, sonography, computed tomography, nuclear medicine scans, and magnetic resonance imaging. State the benefits of and barriers to use of contrast enhancement for these studies.
Provide indications for hospital admission and cite the reasons for admission to various locations in the hospital system, such as a short‐stay unit, surgical or medical ward, step‐down intensive care unit, or intensive care unit.
Cite reasons for patient transfer to a referral center in cases requiring pediatric‐specific services not available at the local facility.
Identify specific evaluation and treatment needs for technology dependent children who present with an acute abdomen, including children with feeding and drainage tubes (gastrostomy, jejunostomy, ileosotomy, and others), long term vascular access devices (ports, Hickman catheters, and others), shunts (ventricular, other), ventilator dependence, and other implanted devices.
Summarize the approach toward pain control in patients presenting with acute abdominal pain, attending to medication choice, delivery method, and impact on exam re‐assessments.
Skills
Pediatric hospitalists should be able to:
Obtain an accurate history and perform a thorough physical examination.
Formulate a targeted differential diagnosis based on elements from the history and physical examination, prior to ordering studies.
Identify the child with an acute abdomen.
Identify and manage the child with concomitant hypovolemia or sepsis.
Direct an appropriate and cost‐effective evaluation to identify the cause of the abdominal pain or the acute abdomen.
Access radiology services efficiently, for both performance and interpretation of studies.
Order and correctly interpret commonly performed basic diagnostic imaging studies and laboratory studies.
Consult surgeons effectively and efficiently when indicated.
Identify the child requiring emergent surgical consultation.
Provide pre‐ and post‐operative general pediatric care for the child requiring surgery, as appropriate, including pain management.
Coordinate care with the primary care provider and arrange an appropriate transition plan for hospital discharge.
Attitudes
Pediatric hospitalists should be able to:
Assume responsibility for care of patients as the primary attending or in collaboration with the surgical team.
Communicate effectively with patients, the family/caregiver, and healthcare providers regarding findings and care plans.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Educate healthcare providers, trainees, the family/caregiver regarding the signs and symptoms of the acute abdomen to encourage early detection and prompt evaluation.
Lead, coordinate or participate in a multidisciplinary team to provide optimal care for children with acute abdominal pain with and without acute abdomen.
Incorporate knowledge of outcomes research and cost management strategies into the evaluation and treatment of patients with an acute abdomen.
Lead, coordinate or participate in institutional efforts to improve the expediency of diagnostic laboratory and radiographic studies, availability of specialty care, and other resources for patients with acute abdominal pain and acute abdomen.
Copyright © 2010 Society of Hospital Medicine
Newborn care and delivery room management
Introduction
Pediatric hospitalists are often asked to support delivery and newborn services. For those who provide these services, the components vary and may include any combination of normal newborn examination and discharge, emergency delivery care, level II neonatal intensive care stabilization, level II neonatal care, or neonatal intensive care transport services. Rendering this care requires medical and procedural skills, as well as leadership and team skills while working with obstetricians, nurses, nurse midwives, advanced practice nurses, primary care providers, neonatologists, and families. Pediatric hospitalists are well positioned to provide care for the immediate newborn and assure effective transition of care at transport or discharge home.
Knowledge
Pediatric hospitalists should be able to:
Describe the role of each team member commonly involved in newborn care, including the obstetrician, prenatal ultrasonographers/radiologists, primary care providers, nurses, lactation consultants, and others.
Review the basic physiologic differences between the preterm and term infant, attending to cardiopulmonary needs, respiratory control, feeding issues, and other elements.
Discuss the impact of maternal factors on the fetus and newborn, including abnormal pre‐natal labs, maternal diabetes, thyroid disorders, and prescription, non‐prescription and illicit drug use.
Define nursery care levels and give an example of infants should be cared for at each level.
Describe the normal delivery process and the physiologic transitions of a newborn infant.
Describe the skills needed to be an effective resuscitation team leader, including critical thinking, evidence‐based decision‐making, and use of continuous quality improvement principles.
Describe the benefits of breast milk, formulas and supplements (Vitamin D, Iron) in infant nutrition for term and preterm infants.
Review the components of newborn screening, and state which tests are performed locally.
Discuss factors influencing bilirubin levels and summarize current guidelines for treatment of jaundice.
Review guidelines for common neonatal care such as immunizations, Vitamin K, eye prophylaxis, hearing screening, car seat trials and electrolyte and bilirubin screening.
Discuss the role of maternal group B streptococcal screen, and presence or absence of chorioamnionitis in the management of the newborn.
Describe the diagnostic and therapeutic approach toward newborns with common dysmorphisms, including features associated with trisomies, ear pits, cleft‐lip/palate, supranummary digits, and clubfoot.
Describe the approach toward the diagnosis and treatment of common infections and toxic exposures of newborns.
Describe the pathophysiology of persistent fetal circulation/pulmonary hypertension.
Describe stabilization techniques and list the differential diagnoses for newborns with seizures.
Review the role of pre‐natal ultrasounds and describe appropriate post‐birth follow‐up of common findings, such as umbilical cord anomalies, renal abnormalities and heart lesions.
List the clinical indications for an acute metabolic or endocrine work‐up in newborns.
Compare and contrast the characteristics of benign versus pathologic cardiac murmurs, and describe the role of oxygen saturation testing.
Discuss the appropriate interventions for a cardiac murmur, including indications for and timing of cardiology consultation
Describe the elements of a safe discharge, attending to timing and follow‐up plans.
Skills
Pediatric hospitalists should be able to:
Maintain Neonatal Resuscitation Program (NRP) certification.
Provide care that incorporates current best practices for oxygen at delivery, infant warming, and treatment of asphyxia.
Correctly order and manage enteral and parenteral nutrition for neonates.
Perform a comprehensive exam and document normal and abnormal variants, including complications of delivery.
Initiate an NRP‐based infant resuscitation, effectively leading the team in the resuscitation of an extremely premature to term infant.
Provide leadership for a normal newborn or level II nursery in partnership with neonatologists and other subspecialists as indicated.
Identify infants with respiratory and cardiac problems and appropriately initiate cardiorespiratory support.
Accurately perform procedures such as lumbar puncture, placement of enteral tubes, umbilical catheters, venous access, intraosseous placement, exchange transfusion and needle thoracotomy or chest tube placement.
Correctly identify newborns requiring subspecialty consultation and counseling such as those with ambiguous genitalia, dysmorphisms, and others and effectively coordinate the referral and subsequent care as indicated.
Recognize and provide initial care for newborns with surgical emergencies, such as infants with gastrointestinal obstruction, diaphragmatic hernia, and others.
Attitudes
Pediatric hospitalists should be able to:
Demonstrate a consistent level of commitment, responsibility, and accountability in rendering patient care for newborns
Role model professional behavior, demonstrating compassion for women and families during the delivery process, when discussing care options, and consultation or referral need, as indicated.
Communicate effectively with patients, the family/caregiver and healthcare providers regarding findings and care plans including post‐discharge needs.
Recognize and respect decisions of the family/caregiver regarding care of extremely premature infants or infants with anomalies.
Systems Organization and Improvement
In order to improve efficiency and quality in their organizations, pediatric hospitalists should:
Lead, coordinate or participate in the development and implementation of cost‐effective, evidence‐based care pathways to standardize the evaluation, management and discharge process for newborns.
Work with hospital administration, hospital staff, subspecialists, and other services/consultants to provide appropriate newborn resuscitation services.
Collaborate with hospital administration and community partners to develop and sustain referral networks between local facilities and tertiary referral centers for newborns requiring tertiary care.
Introduction
Pediatric hospitalists are often asked to support delivery and newborn services. For those who provide these services, the components vary and may include any combination of normal newborn examination and discharge, emergency delivery care, level II neonatal intensive care stabilization, level II neonatal care, or neonatal intensive care transport services. Rendering this care requires medical and procedural skills, as well as leadership and team skills while working with obstetricians, nurses, nurse midwives, advanced practice nurses, primary care providers, neonatologists, and families. Pediatric hospitalists are well positioned to provide care for the immediate newborn and assure effective transition of care at transport or discharge home.
Knowledge
Pediatric hospitalists should be able to:
Describe the role of each team member commonly involved in newborn care, including the obstetrician, prenatal ultrasonographers/radiologists, primary care providers, nurses, lactation consultants, and others.
Review the basic physiologic differences between the preterm and term infant, attending to cardiopulmonary needs, respiratory control, feeding issues, and other elements.
Discuss the impact of maternal factors on the fetus and newborn, including abnormal pre‐natal labs, maternal diabetes, thyroid disorders, and prescription, non‐prescription and illicit drug use.
Define nursery care levels and give an example of infants should be cared for at each level.
Describe the normal delivery process and the physiologic transitions of a newborn infant.
Describe the skills needed to be an effective resuscitation team leader, including critical thinking, evidence‐based decision‐making, and use of continuous quality improvement principles.
Describe the benefits of breast milk, formulas and supplements (Vitamin D, Iron) in infant nutrition for term and preterm infants.
Review the components of newborn screening, and state which tests are performed locally.
Discuss factors influencing bilirubin levels and summarize current guidelines for treatment of jaundice.
Review guidelines for common neonatal care such as immunizations, Vitamin K, eye prophylaxis, hearing screening, car seat trials and electrolyte and bilirubin screening.
Discuss the role of maternal group B streptococcal screen, and presence or absence of chorioamnionitis in the management of the newborn.
Describe the diagnostic and therapeutic approach toward newborns with common dysmorphisms, including features associated with trisomies, ear pits, cleft‐lip/palate, supranummary digits, and clubfoot.
Describe the approach toward the diagnosis and treatment of common infections and toxic exposures of newborns.
Describe the pathophysiology of persistent fetal circulation/pulmonary hypertension.
Describe stabilization techniques and list the differential diagnoses for newborns with seizures.
Review the role of pre‐natal ultrasounds and describe appropriate post‐birth follow‐up of common findings, such as umbilical cord anomalies, renal abnormalities and heart lesions.
List the clinical indications for an acute metabolic or endocrine work‐up in newborns.
Compare and contrast the characteristics of benign versus pathologic cardiac murmurs, and describe the role of oxygen saturation testing.
Discuss the appropriate interventions for a cardiac murmur, including indications for and timing of cardiology consultation
Describe the elements of a safe discharge, attending to timing and follow‐up plans.
Skills
Pediatric hospitalists should be able to:
Maintain Neonatal Resuscitation Program (NRP) certification.
Provide care that incorporates current best practices for oxygen at delivery, infant warming, and treatment of asphyxia.
Correctly order and manage enteral and parenteral nutrition for neonates.
Perform a comprehensive exam and document normal and abnormal variants, including complications of delivery.
Initiate an NRP‐based infant resuscitation, effectively leading the team in the resuscitation of an extremely premature to term infant.
Provide leadership for a normal newborn or level II nursery in partnership with neonatologists and other subspecialists as indicated.
Identify infants with respiratory and cardiac problems and appropriately initiate cardiorespiratory support.
Accurately perform procedures such as lumbar puncture, placement of enteral tubes, umbilical catheters, venous access, intraosseous placement, exchange transfusion and needle thoracotomy or chest tube placement.
Correctly identify newborns requiring subspecialty consultation and counseling such as those with ambiguous genitalia, dysmorphisms, and others and effectively coordinate the referral and subsequent care as indicated.
Recognize and provide initial care for newborns with surgical emergencies, such as infants with gastrointestinal obstruction, diaphragmatic hernia, and others.
Attitudes
Pediatric hospitalists should be able to:
Demonstrate a consistent level of commitment, responsibility, and accountability in rendering patient care for newborns
Role model professional behavior, demonstrating compassion for women and families during the delivery process, when discussing care options, and consultation or referral need, as indicated.
Communicate effectively with patients, the family/caregiver and healthcare providers regarding findings and care plans including post‐discharge needs.
Recognize and respect decisions of the family/caregiver regarding care of extremely premature infants or infants with anomalies.
Systems Organization and Improvement
In order to improve efficiency and quality in their organizations, pediatric hospitalists should:
Lead, coordinate or participate in the development and implementation of cost‐effective, evidence‐based care pathways to standardize the evaluation, management and discharge process for newborns.
Work with hospital administration, hospital staff, subspecialists, and other services/consultants to provide appropriate newborn resuscitation services.
Collaborate with hospital administration and community partners to develop and sustain referral networks between local facilities and tertiary referral centers for newborns requiring tertiary care.
Introduction
Pediatric hospitalists are often asked to support delivery and newborn services. For those who provide these services, the components vary and may include any combination of normal newborn examination and discharge, emergency delivery care, level II neonatal intensive care stabilization, level II neonatal care, or neonatal intensive care transport services. Rendering this care requires medical and procedural skills, as well as leadership and team skills while working with obstetricians, nurses, nurse midwives, advanced practice nurses, primary care providers, neonatologists, and families. Pediatric hospitalists are well positioned to provide care for the immediate newborn and assure effective transition of care at transport or discharge home.
Knowledge
Pediatric hospitalists should be able to:
Describe the role of each team member commonly involved in newborn care, including the obstetrician, prenatal ultrasonographers/radiologists, primary care providers, nurses, lactation consultants, and others.
Review the basic physiologic differences between the preterm and term infant, attending to cardiopulmonary needs, respiratory control, feeding issues, and other elements.
Discuss the impact of maternal factors on the fetus and newborn, including abnormal pre‐natal labs, maternal diabetes, thyroid disorders, and prescription, non‐prescription and illicit drug use.
Define nursery care levels and give an example of infants should be cared for at each level.
Describe the normal delivery process and the physiologic transitions of a newborn infant.
Describe the skills needed to be an effective resuscitation team leader, including critical thinking, evidence‐based decision‐making, and use of continuous quality improvement principles.
Describe the benefits of breast milk, formulas and supplements (Vitamin D, Iron) in infant nutrition for term and preterm infants.
Review the components of newborn screening, and state which tests are performed locally.
Discuss factors influencing bilirubin levels and summarize current guidelines for treatment of jaundice.
Review guidelines for common neonatal care such as immunizations, Vitamin K, eye prophylaxis, hearing screening, car seat trials and electrolyte and bilirubin screening.
Discuss the role of maternal group B streptococcal screen, and presence or absence of chorioamnionitis in the management of the newborn.
Describe the diagnostic and therapeutic approach toward newborns with common dysmorphisms, including features associated with trisomies, ear pits, cleft‐lip/palate, supranummary digits, and clubfoot.
Describe the approach toward the diagnosis and treatment of common infections and toxic exposures of newborns.
Describe the pathophysiology of persistent fetal circulation/pulmonary hypertension.
Describe stabilization techniques and list the differential diagnoses for newborns with seizures.
Review the role of pre‐natal ultrasounds and describe appropriate post‐birth follow‐up of common findings, such as umbilical cord anomalies, renal abnormalities and heart lesions.
List the clinical indications for an acute metabolic or endocrine work‐up in newborns.
Compare and contrast the characteristics of benign versus pathologic cardiac murmurs, and describe the role of oxygen saturation testing.
Discuss the appropriate interventions for a cardiac murmur, including indications for and timing of cardiology consultation
Describe the elements of a safe discharge, attending to timing and follow‐up plans.
Skills
Pediatric hospitalists should be able to:
Maintain Neonatal Resuscitation Program (NRP) certification.
Provide care that incorporates current best practices for oxygen at delivery, infant warming, and treatment of asphyxia.
Correctly order and manage enteral and parenteral nutrition for neonates.
Perform a comprehensive exam and document normal and abnormal variants, including complications of delivery.
Initiate an NRP‐based infant resuscitation, effectively leading the team in the resuscitation of an extremely premature to term infant.
Provide leadership for a normal newborn or level II nursery in partnership with neonatologists and other subspecialists as indicated.
Identify infants with respiratory and cardiac problems and appropriately initiate cardiorespiratory support.
Accurately perform procedures such as lumbar puncture, placement of enteral tubes, umbilical catheters, venous access, intraosseous placement, exchange transfusion and needle thoracotomy or chest tube placement.
Correctly identify newborns requiring subspecialty consultation and counseling such as those with ambiguous genitalia, dysmorphisms, and others and effectively coordinate the referral and subsequent care as indicated.
Recognize and provide initial care for newborns with surgical emergencies, such as infants with gastrointestinal obstruction, diaphragmatic hernia, and others.
Attitudes
Pediatric hospitalists should be able to:
Demonstrate a consistent level of commitment, responsibility, and accountability in rendering patient care for newborns
Role model professional behavior, demonstrating compassion for women and families during the delivery process, when discussing care options, and consultation or referral need, as indicated.
Communicate effectively with patients, the family/caregiver and healthcare providers regarding findings and care plans including post‐discharge needs.
Recognize and respect decisions of the family/caregiver regarding care of extremely premature infants or infants with anomalies.
Systems Organization and Improvement
In order to improve efficiency and quality in their organizations, pediatric hospitalists should:
Lead, coordinate or participate in the development and implementation of cost‐effective, evidence‐based care pathways to standardize the evaluation, management and discharge process for newborns.
Work with hospital administration, hospital staff, subspecialists, and other services/consultants to provide appropriate newborn resuscitation services.
Collaborate with hospital administration and community partners to develop and sustain referral networks between local facilities and tertiary referral centers for newborns requiring tertiary care.
Copyright © 2010 Society of Hospital Medicine