User login
Lumbar puncture
Introduction
Lumbar puncture is a common typically performed procedure to confirm clinical suspicion of meningitis. Other common indications include the evaluation and diagnosis of pseudotumor cerebri, complex migraine headaches, altered mental status, subarachnoid hemorrhage, neurologic deterioration, and demyelinating diseases such as Guillan Barr. A lumbar puncture or spinal tap often elicits great concern from both patients and the family/caregiver due to a misunderstanding of risk to the spinal cord. Adequate discussion with patients and the family/caregiver, and appropriate use of topical anesthesia, anxiolysis, or sedation can create the environment needed for a successful procedure. Pediatric hospitalists frequently encounter patients requiring lumbar puncture and should be adept at performing lumbar puncture in all appropriately selected pediatric patients.
Knowledge
Pediatric hospitalists should be able to:
List the indications for lumbar puncture, such as confirmation of pleocytosis, aiding initial antimicrobial selection, therapeutic removal of fluid, assessment of response to treatment, performance of neurometabolic studies, and others.
Review the basic anatomy of the spine and spinal column.
List the indications for obtaining an imaging study of the brain or spinal cord prior to performing a lumbar puncture.
Describe the relative contraindications to lumbar puncture such as pre‐existing ventriculoperitoneal shunt or previous spinal surgeries and discuss the options for safely obtaining cerebrospinal fluid in these patients
List the absolute contraindications to lumbar puncture, such as increased intracranial pressure, unstable cardiorespiratory status, unstable coagulopathies, and others.
Describe the risks and complications of lumbar puncture attending to infection, bleeding, nerve injury, pain, post‐procedure headache, and others.
Summarize factors that may increase risk for complications such as age, disease process, and anatomy.
Review the steps in performing a lumbar puncture, attending to aspects such as infection control, patient identification, positioning options, monitoring, family/caregiver presence and others.
Discuss the roles of each member of the healthcare team, attending to proper level of monitoring to maximize safety, timeout, documentation, specimen labeling and transport to the laboratory, and communication with patients and the family/caregiver.
Skills
Pediatric hospitalists should be able to:
Perform a pre‐procedural evaluation to determine risks and benefits of lumbar puncture.
Correctly obtain informed consent from the family/caregiver.
Correctly order and ensure proper performance of procedural sedation if indicated, including assurance of adequate number of staff present for both the lumbar puncture and the sedation.
Demonstrate proficiency in performance of lumbar puncture on infants, children, and adolescents.
Correctly identify the need for and efficiently offer education to healthcare providers on proper techniques for holding and calming patients before, during, and after lumbar puncture attempts.
Consistently adhere to infection control practices.
Order appropriate monitoring and correctly interpret monitor data.
Identify complications and respond with appropriate actions.
Accurately use the pressure manometer as appropriate.
Correctly identify the need for and efficiently access appropriate consultants and support services for assistance with pain management, sedation, and performance of a lumbar puncture.
Attitudes
Pediatric hospitalists should be able to:
Work collaboratively with hospital staff and subspecialists to ensure coordinated planning and performance of lumbar punctures.
Communicate effectively with patients and the family/caregiver regarding the indications for, risks, benefits, and steps of the procedure.
Role model and advocate for strict adherence to infection control practices.
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 lumbar punctures for children.
Work with hospital administration, hospital staff and others to develop and implement standardized documentation tools for the procedure.
Lead, coordinate or participate in the development and implementation of a system for review of family/caregiver and healthcare provider satisfaction into procedural strategies.
Introduction
Lumbar puncture is a common typically performed procedure to confirm clinical suspicion of meningitis. Other common indications include the evaluation and diagnosis of pseudotumor cerebri, complex migraine headaches, altered mental status, subarachnoid hemorrhage, neurologic deterioration, and demyelinating diseases such as Guillan Barr. A lumbar puncture or spinal tap often elicits great concern from both patients and the family/caregiver due to a misunderstanding of risk to the spinal cord. Adequate discussion with patients and the family/caregiver, and appropriate use of topical anesthesia, anxiolysis, or sedation can create the environment needed for a successful procedure. Pediatric hospitalists frequently encounter patients requiring lumbar puncture and should be adept at performing lumbar puncture in all appropriately selected pediatric patients.
Knowledge
Pediatric hospitalists should be able to:
List the indications for lumbar puncture, such as confirmation of pleocytosis, aiding initial antimicrobial selection, therapeutic removal of fluid, assessment of response to treatment, performance of neurometabolic studies, and others.
Review the basic anatomy of the spine and spinal column.
List the indications for obtaining an imaging study of the brain or spinal cord prior to performing a lumbar puncture.
Describe the relative contraindications to lumbar puncture such as pre‐existing ventriculoperitoneal shunt or previous spinal surgeries and discuss the options for safely obtaining cerebrospinal fluid in these patients
List the absolute contraindications to lumbar puncture, such as increased intracranial pressure, unstable cardiorespiratory status, unstable coagulopathies, and others.
Describe the risks and complications of lumbar puncture attending to infection, bleeding, nerve injury, pain, post‐procedure headache, and others.
Summarize factors that may increase risk for complications such as age, disease process, and anatomy.
Review the steps in performing a lumbar puncture, attending to aspects such as infection control, patient identification, positioning options, monitoring, family/caregiver presence and others.
Discuss the roles of each member of the healthcare team, attending to proper level of monitoring to maximize safety, timeout, documentation, specimen labeling and transport to the laboratory, and communication with patients and the family/caregiver.
Skills
Pediatric hospitalists should be able to:
Perform a pre‐procedural evaluation to determine risks and benefits of lumbar puncture.
Correctly obtain informed consent from the family/caregiver.
Correctly order and ensure proper performance of procedural sedation if indicated, including assurance of adequate number of staff present for both the lumbar puncture and the sedation.
Demonstrate proficiency in performance of lumbar puncture on infants, children, and adolescents.
Correctly identify the need for and efficiently offer education to healthcare providers on proper techniques for holding and calming patients before, during, and after lumbar puncture attempts.
Consistently adhere to infection control practices.
Order appropriate monitoring and correctly interpret monitor data.
Identify complications and respond with appropriate actions.
Accurately use the pressure manometer as appropriate.
Correctly identify the need for and efficiently access appropriate consultants and support services for assistance with pain management, sedation, and performance of a lumbar puncture.
Attitudes
Pediatric hospitalists should be able to:
Work collaboratively with hospital staff and subspecialists to ensure coordinated planning and performance of lumbar punctures.
Communicate effectively with patients and the family/caregiver regarding the indications for, risks, benefits, and steps of the procedure.
Role model and advocate for strict adherence to infection control practices.
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 lumbar punctures for children.
Work with hospital administration, hospital staff and others to develop and implement standardized documentation tools for the procedure.
Lead, coordinate or participate in the development and implementation of a system for review of family/caregiver and healthcare provider satisfaction into procedural strategies.
Introduction
Lumbar puncture is a common typically performed procedure to confirm clinical suspicion of meningitis. Other common indications include the evaluation and diagnosis of pseudotumor cerebri, complex migraine headaches, altered mental status, subarachnoid hemorrhage, neurologic deterioration, and demyelinating diseases such as Guillan Barr. A lumbar puncture or spinal tap often elicits great concern from both patients and the family/caregiver due to a misunderstanding of risk to the spinal cord. Adequate discussion with patients and the family/caregiver, and appropriate use of topical anesthesia, anxiolysis, or sedation can create the environment needed for a successful procedure. Pediatric hospitalists frequently encounter patients requiring lumbar puncture and should be adept at performing lumbar puncture in all appropriately selected pediatric patients.
Knowledge
Pediatric hospitalists should be able to:
List the indications for lumbar puncture, such as confirmation of pleocytosis, aiding initial antimicrobial selection, therapeutic removal of fluid, assessment of response to treatment, performance of neurometabolic studies, and others.
Review the basic anatomy of the spine and spinal column.
List the indications for obtaining an imaging study of the brain or spinal cord prior to performing a lumbar puncture.
Describe the relative contraindications to lumbar puncture such as pre‐existing ventriculoperitoneal shunt or previous spinal surgeries and discuss the options for safely obtaining cerebrospinal fluid in these patients
List the absolute contraindications to lumbar puncture, such as increased intracranial pressure, unstable cardiorespiratory status, unstable coagulopathies, and others.
Describe the risks and complications of lumbar puncture attending to infection, bleeding, nerve injury, pain, post‐procedure headache, and others.
Summarize factors that may increase risk for complications such as age, disease process, and anatomy.
Review the steps in performing a lumbar puncture, attending to aspects such as infection control, patient identification, positioning options, monitoring, family/caregiver presence and others.
Discuss the roles of each member of the healthcare team, attending to proper level of monitoring to maximize safety, timeout, documentation, specimen labeling and transport to the laboratory, and communication with patients and the family/caregiver.
Skills
Pediatric hospitalists should be able to:
Perform a pre‐procedural evaluation to determine risks and benefits of lumbar puncture.
Correctly obtain informed consent from the family/caregiver.
Correctly order and ensure proper performance of procedural sedation if indicated, including assurance of adequate number of staff present for both the lumbar puncture and the sedation.
Demonstrate proficiency in performance of lumbar puncture on infants, children, and adolescents.
Correctly identify the need for and efficiently offer education to healthcare providers on proper techniques for holding and calming patients before, during, and after lumbar puncture attempts.
Consistently adhere to infection control practices.
Order appropriate monitoring and correctly interpret monitor data.
Identify complications and respond with appropriate actions.
Accurately use the pressure manometer as appropriate.
Correctly identify the need for and efficiently access appropriate consultants and support services for assistance with pain management, sedation, and performance of a lumbar puncture.
Attitudes
Pediatric hospitalists should be able to:
Work collaboratively with hospital staff and subspecialists to ensure coordinated planning and performance of lumbar punctures.
Communicate effectively with patients and the family/caregiver regarding the indications for, risks, benefits, and steps of the procedure.
Role model and advocate for strict adherence to infection control practices.
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 lumbar punctures for children.
Work with hospital administration, hospital staff and others to develop and implement standardized documentation tools for the procedure.
Lead, coordinate or participate in the development and implementation of a system for review of family/caregiver and healthcare provider satisfaction into procedural strategies.
Copyright © 2010 Society of Hospital Medicine
Central nervous system infections
Introduction
Central nervous system (CNS) infections in children vary widely in incidence and severity. Enteroviral meningitis is relatively common and usually resolves without sequelae. In contrast, viral encephalitides and suppurative CNS infections are less common, but are associated with significant mortality and long‐term morbidity in survivors. Children with CNS implanted devices are particularly diagnostically challenging. All of these infections require prompt diagnosis and initiation of therapy which may require coordination of care with neurologists, neurosurgeons, infectious diseases, neuroradiologists and other subspecialists for optimal outcomes. Pediatric hospitalists are often in the best position to render both coordinated acute care and transition to outpatient care or rehabilitation facility.
Knowledge
Pediatric hospitalists should be able to:
Describe the features of the history (such as back pain, trauma, sinus disease, emesis and others) that suggest CNS infections for varied age groups, including those features that differentiate encephalitis, meningitis, brain abscess, and spinal epidural abscess.
List the physical examination findings (such as focal neurologic findings, rash, mental status changes and others) that suggest CNS infections for varied age groups, including those features that differentiate encephalitis, meningitis, brain abscess, and spinal epidural abscess.
List key elements to obtain in the history such as travel, environmental exposures, animal and insect bites, water sources, and explain how each assists with development of a differential diagnosis for potential etiologic pathogens.
Identify the elements of the history and physical examination that may present in a different manner in patients with underlying co‐morbidities such as ventricular shunts/reservoirs, implanted CNS devices, immunosuppressant use, developmental delay and others.
Compare and contrast the cerebrospinal fluid (CSF) analysis values found in viral, bacterial, atypical bacterial and fungal meningitis, encephalitis, brain abscesses, ventricular infections, and suppurative parameningeal foci.
Identify conditions that predispose to focal, suppurative CNS infections.
Discuss the risks, benefits, and indications for lumbar puncture.
State appropriate microbiologic, virologic, and serologic tests utilized to establish a diagnosis.
Compare and contrast the value of computed tomography versus magnetic resonance for imaging possible CNS infections of the head, neck, and spine, attending to sedation needs, local availability, radiation exposure, and value of contrast versus non‐contrast images.
Summarize the indications for imaging for meningitis, encephalitis, brain abscess, ventricular infections, and parameningeal infections stating modality of choice for each diagnosis.
Describe the approach toward initial antimicrobial therapy for CNS infections, attending to age, likely pathogens, and site of infection.
Explain the importance of CNS drug penetration, microbial drug resistance, and age on initial antimicrobial therapy choice.
Name the most common significant complications of CNS infections such as fluid and electrolyte imbalance, seizures, and increase intracranial pressure.
Skills
Pediatric hospitalists should be able to:
Elicit key historical data that may distinguish between types of CNS infections.
Demonstrate proficiency in performing a careful global physical examination to document features to support or refute various infectious etiologies.
Perform a thorough neurologic examination to identify global or focal neurologic deficits.
Efficiently and effectively perform a lumbar puncture.
Determine best patient placement (bed or ward assignment) based on local monitoring and nursing capabilities and patient clinical status.
Initiate appropriate empiric therapy for CNS infections and modify therapy based on proper interpretation of microbiologic, virologic and serologic data.
Anticipate, recognize, and manage acute complications of CNS infections.
Recognize the indications for transfer to higher level of care and effectively coordinate the transfer.
Obtain and coordinate appropriate consults in a timely manner.
Identify patients with neurologic sequelae and make appropriate referrals for therapy and rehabilitation services.
Coordinate care with subspecialists and the primary care provider and arrange an appropriate transition plan for hospital discharge inclusive of therapies, school needs, and psychosocial support.
Consistently adhere to proper infection control practices.
Attitudes
Pediatric hospitalists should be able to:
Engage consultants in sensitive and clear communications with the family/caregiver regarding potential long term neurologic sequelae as appropriate.
Realize the impact of the illness on the family/caregiver, and maintain empathy at all times.
Recognize that the family/caregiver may not assimilate information during times of stress, and that delivering a clear, coherent assessment and plan on repeated occasions may be needed.
Collaborate with subspecialists and the primary care provider to ensure coordinated longitudinal care for children with CNS infection.
Collaborate with public health officials when indicated.
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 CNS infections.
Collaborate with hospital administration, hospital staff, and others to create a multidisciplinary approach toward care and support for children with CNS infections.
Work with hospital and community leaders to assure proper services are available for children requiring short and long term support services.
Introduction
Central nervous system (CNS) infections in children vary widely in incidence and severity. Enteroviral meningitis is relatively common and usually resolves without sequelae. In contrast, viral encephalitides and suppurative CNS infections are less common, but are associated with significant mortality and long‐term morbidity in survivors. Children with CNS implanted devices are particularly diagnostically challenging. All of these infections require prompt diagnosis and initiation of therapy which may require coordination of care with neurologists, neurosurgeons, infectious diseases, neuroradiologists and other subspecialists for optimal outcomes. Pediatric hospitalists are often in the best position to render both coordinated acute care and transition to outpatient care or rehabilitation facility.
Knowledge
Pediatric hospitalists should be able to:
Describe the features of the history (such as back pain, trauma, sinus disease, emesis and others) that suggest CNS infections for varied age groups, including those features that differentiate encephalitis, meningitis, brain abscess, and spinal epidural abscess.
List the physical examination findings (such as focal neurologic findings, rash, mental status changes and others) that suggest CNS infections for varied age groups, including those features that differentiate encephalitis, meningitis, brain abscess, and spinal epidural abscess.
List key elements to obtain in the history such as travel, environmental exposures, animal and insect bites, water sources, and explain how each assists with development of a differential diagnosis for potential etiologic pathogens.
Identify the elements of the history and physical examination that may present in a different manner in patients with underlying co‐morbidities such as ventricular shunts/reservoirs, implanted CNS devices, immunosuppressant use, developmental delay and others.
Compare and contrast the cerebrospinal fluid (CSF) analysis values found in viral, bacterial, atypical bacterial and fungal meningitis, encephalitis, brain abscesses, ventricular infections, and suppurative parameningeal foci.
Identify conditions that predispose to focal, suppurative CNS infections.
Discuss the risks, benefits, and indications for lumbar puncture.
State appropriate microbiologic, virologic, and serologic tests utilized to establish a diagnosis.
Compare and contrast the value of computed tomography versus magnetic resonance for imaging possible CNS infections of the head, neck, and spine, attending to sedation needs, local availability, radiation exposure, and value of contrast versus non‐contrast images.
Summarize the indications for imaging for meningitis, encephalitis, brain abscess, ventricular infections, and parameningeal infections stating modality of choice for each diagnosis.
Describe the approach toward initial antimicrobial therapy for CNS infections, attending to age, likely pathogens, and site of infection.
Explain the importance of CNS drug penetration, microbial drug resistance, and age on initial antimicrobial therapy choice.
Name the most common significant complications of CNS infections such as fluid and electrolyte imbalance, seizures, and increase intracranial pressure.
Skills
Pediatric hospitalists should be able to:
Elicit key historical data that may distinguish between types of CNS infections.
Demonstrate proficiency in performing a careful global physical examination to document features to support or refute various infectious etiologies.
Perform a thorough neurologic examination to identify global or focal neurologic deficits.
Efficiently and effectively perform a lumbar puncture.
Determine best patient placement (bed or ward assignment) based on local monitoring and nursing capabilities and patient clinical status.
Initiate appropriate empiric therapy for CNS infections and modify therapy based on proper interpretation of microbiologic, virologic and serologic data.
Anticipate, recognize, and manage acute complications of CNS infections.
Recognize the indications for transfer to higher level of care and effectively coordinate the transfer.
Obtain and coordinate appropriate consults in a timely manner.
Identify patients with neurologic sequelae and make appropriate referrals for therapy and rehabilitation services.
Coordinate care with subspecialists and the primary care provider and arrange an appropriate transition plan for hospital discharge inclusive of therapies, school needs, and psychosocial support.
Consistently adhere to proper infection control practices.
Attitudes
Pediatric hospitalists should be able to:
Engage consultants in sensitive and clear communications with the family/caregiver regarding potential long term neurologic sequelae as appropriate.
Realize the impact of the illness on the family/caregiver, and maintain empathy at all times.
Recognize that the family/caregiver may not assimilate information during times of stress, and that delivering a clear, coherent assessment and plan on repeated occasions may be needed.
Collaborate with subspecialists and the primary care provider to ensure coordinated longitudinal care for children with CNS infection.
Collaborate with public health officials when indicated.
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 CNS infections.
Collaborate with hospital administration, hospital staff, and others to create a multidisciplinary approach toward care and support for children with CNS infections.
Work with hospital and community leaders to assure proper services are available for children requiring short and long term support services.
Introduction
Central nervous system (CNS) infections in children vary widely in incidence and severity. Enteroviral meningitis is relatively common and usually resolves without sequelae. In contrast, viral encephalitides and suppurative CNS infections are less common, but are associated with significant mortality and long‐term morbidity in survivors. Children with CNS implanted devices are particularly diagnostically challenging. All of these infections require prompt diagnosis and initiation of therapy which may require coordination of care with neurologists, neurosurgeons, infectious diseases, neuroradiologists and other subspecialists for optimal outcomes. Pediatric hospitalists are often in the best position to render both coordinated acute care and transition to outpatient care or rehabilitation facility.
Knowledge
Pediatric hospitalists should be able to:
Describe the features of the history (such as back pain, trauma, sinus disease, emesis and others) that suggest CNS infections for varied age groups, including those features that differentiate encephalitis, meningitis, brain abscess, and spinal epidural abscess.
List the physical examination findings (such as focal neurologic findings, rash, mental status changes and others) that suggest CNS infections for varied age groups, including those features that differentiate encephalitis, meningitis, brain abscess, and spinal epidural abscess.
List key elements to obtain in the history such as travel, environmental exposures, animal and insect bites, water sources, and explain how each assists with development of a differential diagnosis for potential etiologic pathogens.
Identify the elements of the history and physical examination that may present in a different manner in patients with underlying co‐morbidities such as ventricular shunts/reservoirs, implanted CNS devices, immunosuppressant use, developmental delay and others.
Compare and contrast the cerebrospinal fluid (CSF) analysis values found in viral, bacterial, atypical bacterial and fungal meningitis, encephalitis, brain abscesses, ventricular infections, and suppurative parameningeal foci.
Identify conditions that predispose to focal, suppurative CNS infections.
Discuss the risks, benefits, and indications for lumbar puncture.
State appropriate microbiologic, virologic, and serologic tests utilized to establish a diagnosis.
Compare and contrast the value of computed tomography versus magnetic resonance for imaging possible CNS infections of the head, neck, and spine, attending to sedation needs, local availability, radiation exposure, and value of contrast versus non‐contrast images.
Summarize the indications for imaging for meningitis, encephalitis, brain abscess, ventricular infections, and parameningeal infections stating modality of choice for each diagnosis.
Describe the approach toward initial antimicrobial therapy for CNS infections, attending to age, likely pathogens, and site of infection.
Explain the importance of CNS drug penetration, microbial drug resistance, and age on initial antimicrobial therapy choice.
Name the most common significant complications of CNS infections such as fluid and electrolyte imbalance, seizures, and increase intracranial pressure.
Skills
Pediatric hospitalists should be able to:
Elicit key historical data that may distinguish between types of CNS infections.
Demonstrate proficiency in performing a careful global physical examination to document features to support or refute various infectious etiologies.
Perform a thorough neurologic examination to identify global or focal neurologic deficits.
Efficiently and effectively perform a lumbar puncture.
Determine best patient placement (bed or ward assignment) based on local monitoring and nursing capabilities and patient clinical status.
Initiate appropriate empiric therapy for CNS infections and modify therapy based on proper interpretation of microbiologic, virologic and serologic data.
Anticipate, recognize, and manage acute complications of CNS infections.
Recognize the indications for transfer to higher level of care and effectively coordinate the transfer.
Obtain and coordinate appropriate consults in a timely manner.
Identify patients with neurologic sequelae and make appropriate referrals for therapy and rehabilitation services.
Coordinate care with subspecialists and the primary care provider and arrange an appropriate transition plan for hospital discharge inclusive of therapies, school needs, and psychosocial support.
Consistently adhere to proper infection control practices.
Attitudes
Pediatric hospitalists should be able to:
Engage consultants in sensitive and clear communications with the family/caregiver regarding potential long term neurologic sequelae as appropriate.
Realize the impact of the illness on the family/caregiver, and maintain empathy at all times.
Recognize that the family/caregiver may not assimilate information during times of stress, and that delivering a clear, coherent assessment and plan on repeated occasions may be needed.
Collaborate with subspecialists and the primary care provider to ensure coordinated longitudinal care for children with CNS infection.
Collaborate with public health officials when indicated.
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 CNS infections.
Collaborate with hospital administration, hospital staff, and others to create a multidisciplinary approach toward care and support for children with CNS infections.
Work with hospital and community leaders to assure proper services are available for children requiring short and long term support services.
Copyright © 2010 Society of Hospital Medicine
Respiratory failure
Introduction
Respiratory failure is defined by the inability to provide adequate gas exchange, resulting in ineffective alveolar ventilation and/or oxygenation. The respiratory system includes the upper and lower airways, central and peripheral control mechanisms, nerves and muscles. The differential diagnosis for respiratory failure in children is extensive; failure may stem from any portion of the respiratory system. Children with respiratory conditions are frequently hospitalized and may deteriorate, requiring initiation of rapid response teams or transfer to the critical care unit. Pediatric hospitalists frequently encounter children with conditions affecting the respiratory system, and should be able to recognize and treat those who progress to respiratory failure.
Knowledge
Pediatric hospitalists should be able to:
Describe the basic components of the respiratory system, including the upper and lower airways, the central and peripheral regulation systems, peripheral nerves, accessory muscles and diaphragm.
Discuss the basic principles of respiratory physiology such as the alveolar gas equation, minute ventilation, ventilation‐perfusion mismatch, alveolar‐arterial gradient, and others.
Explain the role of the diaphragm and chest wall compliance in development of respiratory failure.
List causes of poor respiratory muscle function, attending to age, neuromuscular disorders, central nervous system dysfunction, nerve injury, and others.
Review the anatomy of the upper airway and discuss why progression to respiratory failure can be rapid in young children.
Describe the differential diagnosis of respiratory distress for children of varying chronological and developmental ages.
State risk factors and diagnostic categories at higher risk for respiratory failure, attending to acute exposures or events and underlying co‐morbidities.
Summarize the modalities commonly available to support the airway and breathing in children with worsening respiratory distress, such as nasopharyngeal or oropharyngeal airways, bag‐valve‐mask ventilation, and endotracheal intubation.
Describe complications due to endotracheal intubation, and state strategies to reduce these risks.
Summarize evaluation, monitoring, and treatment options for patients with worsening respiratory status including mental status assessment, capnography, medications, respiratory support and others.
Describe the signs and symptoms of impending respiratory failure and list criteria for transfer to an intensive care unit.
Skills
Pediatric hospitalists should be able to:
Recognize early warning signs of acute respiratory distress and institute corrective actions to avert further deterioration.
Efficiently stabilize the airway, using effective non‐invasive and invasive airway management techniques in collaboration with other services as appropriate.
Identify patients with risk factors for progression to respiratory failure and assure proper monitoring and patient placement.
Recognize signs of impending respiratory failure and transfer patients to a critical care unit in an efficient and safe manner.
Appropriately order, and interpret oxygenation and ventilation testing results.
Order appropriate monitoring and correctly interpret monitor data.
Correctly diagnose and initiate medical management for systemic causes of respiratory failure.
Demonstrate proficiency in basic management of patients with chronic respiratory support needs.
Identify patients requiring subspecialty care and obtain timely consults.
Attitudes
Pediatric hospitalists should be able to:
Collaborate with patients, the family/caregiver, hospital staff, and subspecialists to ensure coordinated hospital care for children with conditions at risk for respiratory failure.
Provide consultation for healthcare providers in community ambulatory or inpatient settings to ensure proper patient placement and transport of patients to higher acuity settings as needed.
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 develop, implement, and assess outcomes of intervention strategies (rapid response, early warning) for hospitalized patients with deterioration in respiratory status in order to prevent adverse outcomes.
Lead, coordinate or participate in creating educational programs for the family/caregiver, hospital staff, and other healthcare providers regarding recognition of signs and symptoms of respiratory distress in children, particularly those at higher risk for respiratory failure.
Introduction
Respiratory failure is defined by the inability to provide adequate gas exchange, resulting in ineffective alveolar ventilation and/or oxygenation. The respiratory system includes the upper and lower airways, central and peripheral control mechanisms, nerves and muscles. The differential diagnosis for respiratory failure in children is extensive; failure may stem from any portion of the respiratory system. Children with respiratory conditions are frequently hospitalized and may deteriorate, requiring initiation of rapid response teams or transfer to the critical care unit. Pediatric hospitalists frequently encounter children with conditions affecting the respiratory system, and should be able to recognize and treat those who progress to respiratory failure.
Knowledge
Pediatric hospitalists should be able to:
Describe the basic components of the respiratory system, including the upper and lower airways, the central and peripheral regulation systems, peripheral nerves, accessory muscles and diaphragm.
Discuss the basic principles of respiratory physiology such as the alveolar gas equation, minute ventilation, ventilation‐perfusion mismatch, alveolar‐arterial gradient, and others.
Explain the role of the diaphragm and chest wall compliance in development of respiratory failure.
List causes of poor respiratory muscle function, attending to age, neuromuscular disorders, central nervous system dysfunction, nerve injury, and others.
Review the anatomy of the upper airway and discuss why progression to respiratory failure can be rapid in young children.
Describe the differential diagnosis of respiratory distress for children of varying chronological and developmental ages.
State risk factors and diagnostic categories at higher risk for respiratory failure, attending to acute exposures or events and underlying co‐morbidities.
Summarize the modalities commonly available to support the airway and breathing in children with worsening respiratory distress, such as nasopharyngeal or oropharyngeal airways, bag‐valve‐mask ventilation, and endotracheal intubation.
Describe complications due to endotracheal intubation, and state strategies to reduce these risks.
Summarize evaluation, monitoring, and treatment options for patients with worsening respiratory status including mental status assessment, capnography, medications, respiratory support and others.
Describe the signs and symptoms of impending respiratory failure and list criteria for transfer to an intensive care unit.
Skills
Pediatric hospitalists should be able to:
Recognize early warning signs of acute respiratory distress and institute corrective actions to avert further deterioration.
Efficiently stabilize the airway, using effective non‐invasive and invasive airway management techniques in collaboration with other services as appropriate.
Identify patients with risk factors for progression to respiratory failure and assure proper monitoring and patient placement.
Recognize signs of impending respiratory failure and transfer patients to a critical care unit in an efficient and safe manner.
Appropriately order, and interpret oxygenation and ventilation testing results.
Order appropriate monitoring and correctly interpret monitor data.
Correctly diagnose and initiate medical management for systemic causes of respiratory failure.
Demonstrate proficiency in basic management of patients with chronic respiratory support needs.
Identify patients requiring subspecialty care and obtain timely consults.
Attitudes
Pediatric hospitalists should be able to:
Collaborate with patients, the family/caregiver, hospital staff, and subspecialists to ensure coordinated hospital care for children with conditions at risk for respiratory failure.
Provide consultation for healthcare providers in community ambulatory or inpatient settings to ensure proper patient placement and transport of patients to higher acuity settings as needed.
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 develop, implement, and assess outcomes of intervention strategies (rapid response, early warning) for hospitalized patients with deterioration in respiratory status in order to prevent adverse outcomes.
Lead, coordinate or participate in creating educational programs for the family/caregiver, hospital staff, and other healthcare providers regarding recognition of signs and symptoms of respiratory distress in children, particularly those at higher risk for respiratory failure.
Introduction
Respiratory failure is defined by the inability to provide adequate gas exchange, resulting in ineffective alveolar ventilation and/or oxygenation. The respiratory system includes the upper and lower airways, central and peripheral control mechanisms, nerves and muscles. The differential diagnosis for respiratory failure in children is extensive; failure may stem from any portion of the respiratory system. Children with respiratory conditions are frequently hospitalized and may deteriorate, requiring initiation of rapid response teams or transfer to the critical care unit. Pediatric hospitalists frequently encounter children with conditions affecting the respiratory system, and should be able to recognize and treat those who progress to respiratory failure.
Knowledge
Pediatric hospitalists should be able to:
Describe the basic components of the respiratory system, including the upper and lower airways, the central and peripheral regulation systems, peripheral nerves, accessory muscles and diaphragm.
Discuss the basic principles of respiratory physiology such as the alveolar gas equation, minute ventilation, ventilation‐perfusion mismatch, alveolar‐arterial gradient, and others.
Explain the role of the diaphragm and chest wall compliance in development of respiratory failure.
List causes of poor respiratory muscle function, attending to age, neuromuscular disorders, central nervous system dysfunction, nerve injury, and others.
Review the anatomy of the upper airway and discuss why progression to respiratory failure can be rapid in young children.
Describe the differential diagnosis of respiratory distress for children of varying chronological and developmental ages.
State risk factors and diagnostic categories at higher risk for respiratory failure, attending to acute exposures or events and underlying co‐morbidities.
Summarize the modalities commonly available to support the airway and breathing in children with worsening respiratory distress, such as nasopharyngeal or oropharyngeal airways, bag‐valve‐mask ventilation, and endotracheal intubation.
Describe complications due to endotracheal intubation, and state strategies to reduce these risks.
Summarize evaluation, monitoring, and treatment options for patients with worsening respiratory status including mental status assessment, capnography, medications, respiratory support and others.
Describe the signs and symptoms of impending respiratory failure and list criteria for transfer to an intensive care unit.
Skills
Pediatric hospitalists should be able to:
Recognize early warning signs of acute respiratory distress and institute corrective actions to avert further deterioration.
Efficiently stabilize the airway, using effective non‐invasive and invasive airway management techniques in collaboration with other services as appropriate.
Identify patients with risk factors for progression to respiratory failure and assure proper monitoring and patient placement.
Recognize signs of impending respiratory failure and transfer patients to a critical care unit in an efficient and safe manner.
Appropriately order, and interpret oxygenation and ventilation testing results.
Order appropriate monitoring and correctly interpret monitor data.
Correctly diagnose and initiate medical management for systemic causes of respiratory failure.
Demonstrate proficiency in basic management of patients with chronic respiratory support needs.
Identify patients requiring subspecialty care and obtain timely consults.
Attitudes
Pediatric hospitalists should be able to:
Collaborate with patients, the family/caregiver, hospital staff, and subspecialists to ensure coordinated hospital care for children with conditions at risk for respiratory failure.
Provide consultation for healthcare providers in community ambulatory or inpatient settings to ensure proper patient placement and transport of patients to higher acuity settings as needed.
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 develop, implement, and assess outcomes of intervention strategies (rapid response, early warning) for hospitalized patients with deterioration in respiratory status in order to prevent adverse outcomes.
Lead, coordinate or participate in creating educational programs for the family/caregiver, hospital staff, and other healthcare providers regarding recognition of signs and symptoms of respiratory distress in children, particularly those at higher risk for respiratory failure.
Copyright © 2010 Society of Hospital Medicine
Upper airway infections
Introduction
As a group, upper respiratory tract infections in children are responsible for approximately 22 million days of school absence and contribute to work loss due to absence of the family/caregiver caring for ill children. Children under six years of age average six to eight upper respiratory tract infections per year. Although these infections are usually self‐limited, they can be associated with airway obstruction and may be life‐threatening. Laryngotracheobronchitis (croup) is a common cause of upper airway obstruction in children, affecting up to 6% of children under six years of age. Although less than 5% of children with croup are hospitalized, croup account for 35,000 hospital admissions annually and results in the need for endotracheal intubation for 1‐2% of those hospitalized. Other upper airway infections that may lead to airway obstruction include epiglottitis, bacterial tracheitis, severe tonsillitis, and deep neck abscesses. Pediatric hospitalists commonly encounter these patients and are often in the best position to coordinate care across multiple specialties when necessary. Pediatric hospitalists should be able to recognize signs and symptoms of impending or actual airway obstruction, provide immediate care, and arrange for the appropriate subsequent level of care.
Knowledge
Pediatric hospitalists should be able to:
Describe the anatomy of the upper respiratory tract and discuss how abnormalities in airflow in different locations may alter clinical presentation.
Compare and contrast the airway anatomy of neonates, infants, toddlers, preschoolers, school aged children, and adolescents.
Differentiate between the common infectious etiologies of upper airway obstruction in children of various ages.
Review alternate diagnoses which may mimic the presentation of acute upper respiratory infection such as allergic reaction, toxic inhalant exposure, and others.
Describe the signs and symptoms of upper airway obstruction, such as stertor, stridor, tripod positioning, dysphagia, drooling, trismus and others.
List the types of radiographic studies available to assess the upper airway (such as plain radiographs, ultrasonography, computed tomography, and magnetic resonance imaging) and discuss the risks, benefits, and indications for each.
Discuss the indications for nebulized epinephrine, glucocorticoids, antibiotics, and other medications in the treatment of upper respiratory tract infections.
Compare and contrast the benefits and limitations of various modalities of airway stabilization and respiratory support in patients with varying degrees of upper airway obstruction.
List the indications for hospital admission, and explain the utility of various monitoring options.
Discuss the changes in clinical status that indicate need for escalation of care, such as worsening stridor or work of breathing, decreased air entry, cyanosis, altered mental status and others.
Describe the criteria for management in an intensive care unit or transfer to a tertiary care facility.
Review the indications for emergent surgical consultation.
List the criteria for hospital discharge, attending to change in symptoms, oxygenation, hydration, and education.
Skills
Pediatric hospitalists should be able to:
Perform an appropriately focused medical history, attending to symptoms of potential airway obstruction.
Conduct an appropriate physical examination in children with upper respiratory tract infection, attending to signs and symptoms that may indicate the etiology or severity of the infection.
Consistently adhere to infection control practices.
Correctly identify patients with co‐morbidities or potential underlying anatomic abnormalities and order appropriate testing and treatment.
Identify complications of the infection and respond with appropriate actions.
Perform an evidence‐based, cost‐effective diagnostic evaluation and treatment plan, avoiding unnecessary testing as appropriate.
Order appropriate monitoring and correctly interpret monitor data.
Perform careful reassessments daily and as needed, note changes in clinical status and respond with appropriate actions and escalation of care as appropriate.
Stabilize the airway and provide appropriate respiratory support for patients with impending or actual airway obstruction or respiratory failure, or arrange for the appropriate personnel to perform the procedure in a timely and safe manner.
Recognize the indications for and efficiently obtain subspecialty consultation.
Attitudes
Pediatric hospitalists should be able to:
Role model and advocate for strict adherence to infection control practices.
Communicate effectively with patients and the family/caregiver regarding the diagnosis, management plan, and follow‐up needs.
Collaborate with the primary care provider and subspecialists to ensure a coordinated discharge.
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 within a multidisciplinary team for hospitalized children with upper respiratory tract infections.
Collaborate with hospital administration and community partners to develop and sustain referral networks between local facilities and tertiary referral centers for hospitalized patients with upper respiratory tract infections.
Introduction
As a group, upper respiratory tract infections in children are responsible for approximately 22 million days of school absence and contribute to work loss due to absence of the family/caregiver caring for ill children. Children under six years of age average six to eight upper respiratory tract infections per year. Although these infections are usually self‐limited, they can be associated with airway obstruction and may be life‐threatening. Laryngotracheobronchitis (croup) is a common cause of upper airway obstruction in children, affecting up to 6% of children under six years of age. Although less than 5% of children with croup are hospitalized, croup account for 35,000 hospital admissions annually and results in the need for endotracheal intubation for 1‐2% of those hospitalized. Other upper airway infections that may lead to airway obstruction include epiglottitis, bacterial tracheitis, severe tonsillitis, and deep neck abscesses. Pediatric hospitalists commonly encounter these patients and are often in the best position to coordinate care across multiple specialties when necessary. Pediatric hospitalists should be able to recognize signs and symptoms of impending or actual airway obstruction, provide immediate care, and arrange for the appropriate subsequent level of care.
Knowledge
Pediatric hospitalists should be able to:
Describe the anatomy of the upper respiratory tract and discuss how abnormalities in airflow in different locations may alter clinical presentation.
Compare and contrast the airway anatomy of neonates, infants, toddlers, preschoolers, school aged children, and adolescents.
Differentiate between the common infectious etiologies of upper airway obstruction in children of various ages.
Review alternate diagnoses which may mimic the presentation of acute upper respiratory infection such as allergic reaction, toxic inhalant exposure, and others.
Describe the signs and symptoms of upper airway obstruction, such as stertor, stridor, tripod positioning, dysphagia, drooling, trismus and others.
List the types of radiographic studies available to assess the upper airway (such as plain radiographs, ultrasonography, computed tomography, and magnetic resonance imaging) and discuss the risks, benefits, and indications for each.
Discuss the indications for nebulized epinephrine, glucocorticoids, antibiotics, and other medications in the treatment of upper respiratory tract infections.
Compare and contrast the benefits and limitations of various modalities of airway stabilization and respiratory support in patients with varying degrees of upper airway obstruction.
List the indications for hospital admission, and explain the utility of various monitoring options.
Discuss the changes in clinical status that indicate need for escalation of care, such as worsening stridor or work of breathing, decreased air entry, cyanosis, altered mental status and others.
Describe the criteria for management in an intensive care unit or transfer to a tertiary care facility.
Review the indications for emergent surgical consultation.
List the criteria for hospital discharge, attending to change in symptoms, oxygenation, hydration, and education.
Skills
Pediatric hospitalists should be able to:
Perform an appropriately focused medical history, attending to symptoms of potential airway obstruction.
Conduct an appropriate physical examination in children with upper respiratory tract infection, attending to signs and symptoms that may indicate the etiology or severity of the infection.
Consistently adhere to infection control practices.
Correctly identify patients with co‐morbidities or potential underlying anatomic abnormalities and order appropriate testing and treatment.
Identify complications of the infection and respond with appropriate actions.
Perform an evidence‐based, cost‐effective diagnostic evaluation and treatment plan, avoiding unnecessary testing as appropriate.
Order appropriate monitoring and correctly interpret monitor data.
Perform careful reassessments daily and as needed, note changes in clinical status and respond with appropriate actions and escalation of care as appropriate.
Stabilize the airway and provide appropriate respiratory support for patients with impending or actual airway obstruction or respiratory failure, or arrange for the appropriate personnel to perform the procedure in a timely and safe manner.
Recognize the indications for and efficiently obtain subspecialty consultation.
Attitudes
Pediatric hospitalists should be able to:
Role model and advocate for strict adherence to infection control practices.
Communicate effectively with patients and the family/caregiver regarding the diagnosis, management plan, and follow‐up needs.
Collaborate with the primary care provider and subspecialists to ensure a coordinated discharge.
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 within a multidisciplinary team for hospitalized children with upper respiratory tract infections.
Collaborate with hospital administration and community partners to develop and sustain referral networks between local facilities and tertiary referral centers for hospitalized patients with upper respiratory tract infections.
Introduction
As a group, upper respiratory tract infections in children are responsible for approximately 22 million days of school absence and contribute to work loss due to absence of the family/caregiver caring for ill children. Children under six years of age average six to eight upper respiratory tract infections per year. Although these infections are usually self‐limited, they can be associated with airway obstruction and may be life‐threatening. Laryngotracheobronchitis (croup) is a common cause of upper airway obstruction in children, affecting up to 6% of children under six years of age. Although less than 5% of children with croup are hospitalized, croup account for 35,000 hospital admissions annually and results in the need for endotracheal intubation for 1‐2% of those hospitalized. Other upper airway infections that may lead to airway obstruction include epiglottitis, bacterial tracheitis, severe tonsillitis, and deep neck abscesses. Pediatric hospitalists commonly encounter these patients and are often in the best position to coordinate care across multiple specialties when necessary. Pediatric hospitalists should be able to recognize signs and symptoms of impending or actual airway obstruction, provide immediate care, and arrange for the appropriate subsequent level of care.
Knowledge
Pediatric hospitalists should be able to:
Describe the anatomy of the upper respiratory tract and discuss how abnormalities in airflow in different locations may alter clinical presentation.
Compare and contrast the airway anatomy of neonates, infants, toddlers, preschoolers, school aged children, and adolescents.
Differentiate between the common infectious etiologies of upper airway obstruction in children of various ages.
Review alternate diagnoses which may mimic the presentation of acute upper respiratory infection such as allergic reaction, toxic inhalant exposure, and others.
Describe the signs and symptoms of upper airway obstruction, such as stertor, stridor, tripod positioning, dysphagia, drooling, trismus and others.
List the types of radiographic studies available to assess the upper airway (such as plain radiographs, ultrasonography, computed tomography, and magnetic resonance imaging) and discuss the risks, benefits, and indications for each.
Discuss the indications for nebulized epinephrine, glucocorticoids, antibiotics, and other medications in the treatment of upper respiratory tract infections.
Compare and contrast the benefits and limitations of various modalities of airway stabilization and respiratory support in patients with varying degrees of upper airway obstruction.
List the indications for hospital admission, and explain the utility of various monitoring options.
Discuss the changes in clinical status that indicate need for escalation of care, such as worsening stridor or work of breathing, decreased air entry, cyanosis, altered mental status and others.
Describe the criteria for management in an intensive care unit or transfer to a tertiary care facility.
Review the indications for emergent surgical consultation.
List the criteria for hospital discharge, attending to change in symptoms, oxygenation, hydration, and education.
Skills
Pediatric hospitalists should be able to:
Perform an appropriately focused medical history, attending to symptoms of potential airway obstruction.
Conduct an appropriate physical examination in children with upper respiratory tract infection, attending to signs and symptoms that may indicate the etiology or severity of the infection.
Consistently adhere to infection control practices.
Correctly identify patients with co‐morbidities or potential underlying anatomic abnormalities and order appropriate testing and treatment.
Identify complications of the infection and respond with appropriate actions.
Perform an evidence‐based, cost‐effective diagnostic evaluation and treatment plan, avoiding unnecessary testing as appropriate.
Order appropriate monitoring and correctly interpret monitor data.
Perform careful reassessments daily and as needed, note changes in clinical status and respond with appropriate actions and escalation of care as appropriate.
Stabilize the airway and provide appropriate respiratory support for patients with impending or actual airway obstruction or respiratory failure, or arrange for the appropriate personnel to perform the procedure in a timely and safe manner.
Recognize the indications for and efficiently obtain subspecialty consultation.
Attitudes
Pediatric hospitalists should be able to:
Role model and advocate for strict adherence to infection control practices.
Communicate effectively with patients and the family/caregiver regarding the diagnosis, management plan, and follow‐up needs.
Collaborate with the primary care provider and subspecialists to ensure a coordinated discharge.
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 within a multidisciplinary team for hospitalized children with upper respiratory tract infections.
Collaborate with hospital administration and community partners to develop and sustain referral networks between local facilities and tertiary referral centers for hospitalized patients with upper respiratory tract infections.
Copyright © 2010 Society of Hospital Medicine
Continuous quality improvement
Introduction
Continuous Quality Improvement (CQI) in Health Care is a structured organizational process that involves physicians and other personnel in planning and implementing ongoing proactive improvements in processes of care to provide quality health care outcomes. CQI is used by hospitals to optimize clinical care by reducing variability and reducing costs, to help meet regulatory requirements, and to enhance customer service quality. The issues of quality improvement gained additional national attention with the 2001 release of the Institute of Medicine (IOM) report titled Crossing the Quality Chasm in which the template was set for quality improvement processes. Pediatric hospitalists are well positioned to promote and champion CQI projects within the hospital setting, working on the front lines of clinical care and acting as influential change agents.
Knowledge
Pediatric hospitalists should be able to:
Distinguish the basic principles of CQI, which focus upon proactively improving processes of care, from Quality Assurance which focuses on conformance quality.
Explain how CQI focuses on systematic improvement and can be effectively used to create clinical care plans as well as hospital procedural guidelines.
Describe the business case for quality, and how quality drives cost.
Discuss the CQI concept of and methods behind Plan Do Study Act (PDSA) and other models to accomplish rapid cycle improvements within the organization.
List common terms and language of CQI and Performance Improvement.
Define commonly used quality terms such as common cause and special cause variation, run charts, cumulative proportion charts, process measures, outcomes, and others.
Explain the role of reliability science and human factors in implementing healthcare improvements.
Summarize how CQI supports effective development of care standardization, best practices, and practice guidelines.
Indicate how evidence‐based medicine can be integrated into the CQI planning stage for appropriate clinical projects.
Explain why building CQI into everyday processes of care is the most effective way to improve quality.
Describe how decreasing unwanted variability in care impacts clinical outcomes.
List the attributes necessary to moderate, facilitate and lead QI and patient safety initiatives and discuss the importance of team building methods.
Describe the components of family centered care and discuss the importance of engaging patients and the family/caregiver in QI efforts.
Identify the principles outlined in the IOM Crossing the Quality Chasm report and stay current with the latest IOM reports on hospital quality.
Describe how external agencies and societies such as The Joint Commission, Child Health Corporation of America, National Association for Children's Hospitals and Related Institutions, Agency for Healthcare Research and Quality, and the National Quality Forum impact quality improvement initiatives for hospitalized children.
Discuss the value of national, state, and local comparative quality data and the utility of national sources such as the Pediatric Health Information Dataset (PHIS).
Describe the quality improvement education expectations of residency programs set by the ACGME and compare and contrast these to those of the American Board of Pediatrics.
Skills
Pediatric hospitalists should be able to:
Lead as a physician champion and early adopter of continuous quality improvement.
Participate in reviews of quality data, including basic data analysis and development of recommendations from the data.
Serve as a liaison between physician staff and hospital administrative staff when interpreting physician‐specific information and clinical care outliers.
Initiate a continuous quality improvement project by identifying a process in need of improvement and engaging the appropriate personnel to implement a change, using CQI principles.
Educate trainees, nursing staff, ancillary staff, peers on the basic principles of CQI and the importance of CQI on child health outcomes.
Assist with development of best practices and practice guidelines to assure consistent, high quality standards and expectations for care in the hospital setting.
Effectively use best practice guidelines.
Demonstrate proficiency in performing a rapid cycle improvement project utilizing the PDSA process.
Demonstrate facility with the use of common computer applications, including spreadsheet and database management for information retrieval and analysis.
Effectively collaborate with appropriate healthcare providers critical to quality improvement efforts such as clinical team members, information technology staff, data analysts, and others.
Attitudes
Pediatric hospitalists should be able to:
Lead as an early adopter and change agent by building an awareness of and consensus for changes needed to make patient care quality a high priority.
Recognize the importance of team building, leadership, and family centeredness in performing effective CQI.
Seek opportunities to initiate or actively participate in CQI projects. Work collaboratively to help create and maintain a CQI culture within the institution.
Model professional behavior when reviewing and interpreting data.
Systems Organization and Improvement
In order to improve efficiency and quality in their organizations, pediatric hospitalists should:
Engage Hospital Senior Management, Hospital Board of Directors and Medical Staff leadership in creating, implementing, and sustaining short and long term quality improvement goals.
Participate on Quality Improvement committees and seek opportunities to serve as Quality Improvement Officers or Consultants.
Advocate for the necessary information systems and other infrastructure to secure accurate data and assure success in the CQI process.
Introduction
Continuous Quality Improvement (CQI) in Health Care is a structured organizational process that involves physicians and other personnel in planning and implementing ongoing proactive improvements in processes of care to provide quality health care outcomes. CQI is used by hospitals to optimize clinical care by reducing variability and reducing costs, to help meet regulatory requirements, and to enhance customer service quality. The issues of quality improvement gained additional national attention with the 2001 release of the Institute of Medicine (IOM) report titled Crossing the Quality Chasm in which the template was set for quality improvement processes. Pediatric hospitalists are well positioned to promote and champion CQI projects within the hospital setting, working on the front lines of clinical care and acting as influential change agents.
Knowledge
Pediatric hospitalists should be able to:
Distinguish the basic principles of CQI, which focus upon proactively improving processes of care, from Quality Assurance which focuses on conformance quality.
Explain how CQI focuses on systematic improvement and can be effectively used to create clinical care plans as well as hospital procedural guidelines.
Describe the business case for quality, and how quality drives cost.
Discuss the CQI concept of and methods behind Plan Do Study Act (PDSA) and other models to accomplish rapid cycle improvements within the organization.
List common terms and language of CQI and Performance Improvement.
Define commonly used quality terms such as common cause and special cause variation, run charts, cumulative proportion charts, process measures, outcomes, and others.
Explain the role of reliability science and human factors in implementing healthcare improvements.
Summarize how CQI supports effective development of care standardization, best practices, and practice guidelines.
Indicate how evidence‐based medicine can be integrated into the CQI planning stage for appropriate clinical projects.
Explain why building CQI into everyday processes of care is the most effective way to improve quality.
Describe how decreasing unwanted variability in care impacts clinical outcomes.
List the attributes necessary to moderate, facilitate and lead QI and patient safety initiatives and discuss the importance of team building methods.
Describe the components of family centered care and discuss the importance of engaging patients and the family/caregiver in QI efforts.
Identify the principles outlined in the IOM Crossing the Quality Chasm report and stay current with the latest IOM reports on hospital quality.
Describe how external agencies and societies such as The Joint Commission, Child Health Corporation of America, National Association for Children's Hospitals and Related Institutions, Agency for Healthcare Research and Quality, and the National Quality Forum impact quality improvement initiatives for hospitalized children.
Discuss the value of national, state, and local comparative quality data and the utility of national sources such as the Pediatric Health Information Dataset (PHIS).
Describe the quality improvement education expectations of residency programs set by the ACGME and compare and contrast these to those of the American Board of Pediatrics.
Skills
Pediatric hospitalists should be able to:
Lead as a physician champion and early adopter of continuous quality improvement.
Participate in reviews of quality data, including basic data analysis and development of recommendations from the data.
Serve as a liaison between physician staff and hospital administrative staff when interpreting physician‐specific information and clinical care outliers.
Initiate a continuous quality improvement project by identifying a process in need of improvement and engaging the appropriate personnel to implement a change, using CQI principles.
Educate trainees, nursing staff, ancillary staff, peers on the basic principles of CQI and the importance of CQI on child health outcomes.
Assist with development of best practices and practice guidelines to assure consistent, high quality standards and expectations for care in the hospital setting.
Effectively use best practice guidelines.
Demonstrate proficiency in performing a rapid cycle improvement project utilizing the PDSA process.
Demonstrate facility with the use of common computer applications, including spreadsheet and database management for information retrieval and analysis.
Effectively collaborate with appropriate healthcare providers critical to quality improvement efforts such as clinical team members, information technology staff, data analysts, and others.
Attitudes
Pediatric hospitalists should be able to:
Lead as an early adopter and change agent by building an awareness of and consensus for changes needed to make patient care quality a high priority.
Recognize the importance of team building, leadership, and family centeredness in performing effective CQI.
Seek opportunities to initiate or actively participate in CQI projects. Work collaboratively to help create and maintain a CQI culture within the institution.
Model professional behavior when reviewing and interpreting data.
Systems Organization and Improvement
In order to improve efficiency and quality in their organizations, pediatric hospitalists should:
Engage Hospital Senior Management, Hospital Board of Directors and Medical Staff leadership in creating, implementing, and sustaining short and long term quality improvement goals.
Participate on Quality Improvement committees and seek opportunities to serve as Quality Improvement Officers or Consultants.
Advocate for the necessary information systems and other infrastructure to secure accurate data and assure success in the CQI process.
Introduction
Continuous Quality Improvement (CQI) in Health Care is a structured organizational process that involves physicians and other personnel in planning and implementing ongoing proactive improvements in processes of care to provide quality health care outcomes. CQI is used by hospitals to optimize clinical care by reducing variability and reducing costs, to help meet regulatory requirements, and to enhance customer service quality. The issues of quality improvement gained additional national attention with the 2001 release of the Institute of Medicine (IOM) report titled Crossing the Quality Chasm in which the template was set for quality improvement processes. Pediatric hospitalists are well positioned to promote and champion CQI projects within the hospital setting, working on the front lines of clinical care and acting as influential change agents.
Knowledge
Pediatric hospitalists should be able to:
Distinguish the basic principles of CQI, which focus upon proactively improving processes of care, from Quality Assurance which focuses on conformance quality.
Explain how CQI focuses on systematic improvement and can be effectively used to create clinical care plans as well as hospital procedural guidelines.
Describe the business case for quality, and how quality drives cost.
Discuss the CQI concept of and methods behind Plan Do Study Act (PDSA) and other models to accomplish rapid cycle improvements within the organization.
List common terms and language of CQI and Performance Improvement.
Define commonly used quality terms such as common cause and special cause variation, run charts, cumulative proportion charts, process measures, outcomes, and others.
Explain the role of reliability science and human factors in implementing healthcare improvements.
Summarize how CQI supports effective development of care standardization, best practices, and practice guidelines.
Indicate how evidence‐based medicine can be integrated into the CQI planning stage for appropriate clinical projects.
Explain why building CQI into everyday processes of care is the most effective way to improve quality.
Describe how decreasing unwanted variability in care impacts clinical outcomes.
List the attributes necessary to moderate, facilitate and lead QI and patient safety initiatives and discuss the importance of team building methods.
Describe the components of family centered care and discuss the importance of engaging patients and the family/caregiver in QI efforts.
Identify the principles outlined in the IOM Crossing the Quality Chasm report and stay current with the latest IOM reports on hospital quality.
Describe how external agencies and societies such as The Joint Commission, Child Health Corporation of America, National Association for Children's Hospitals and Related Institutions, Agency for Healthcare Research and Quality, and the National Quality Forum impact quality improvement initiatives for hospitalized children.
Discuss the value of national, state, and local comparative quality data and the utility of national sources such as the Pediatric Health Information Dataset (PHIS).
Describe the quality improvement education expectations of residency programs set by the ACGME and compare and contrast these to those of the American Board of Pediatrics.
Skills
Pediatric hospitalists should be able to:
Lead as a physician champion and early adopter of continuous quality improvement.
Participate in reviews of quality data, including basic data analysis and development of recommendations from the data.
Serve as a liaison between physician staff and hospital administrative staff when interpreting physician‐specific information and clinical care outliers.
Initiate a continuous quality improvement project by identifying a process in need of improvement and engaging the appropriate personnel to implement a change, using CQI principles.
Educate trainees, nursing staff, ancillary staff, peers on the basic principles of CQI and the importance of CQI on child health outcomes.
Assist with development of best practices and practice guidelines to assure consistent, high quality standards and expectations for care in the hospital setting.
Effectively use best practice guidelines.
Demonstrate proficiency in performing a rapid cycle improvement project utilizing the PDSA process.
Demonstrate facility with the use of common computer applications, including spreadsheet and database management for information retrieval and analysis.
Effectively collaborate with appropriate healthcare providers critical to quality improvement efforts such as clinical team members, information technology staff, data analysts, and others.
Attitudes
Pediatric hospitalists should be able to:
Lead as an early adopter and change agent by building an awareness of and consensus for changes needed to make patient care quality a high priority.
Recognize the importance of team building, leadership, and family centeredness in performing effective CQI.
Seek opportunities to initiate or actively participate in CQI projects. Work collaboratively to help create and maintain a CQI culture within the institution.
Model professional behavior when reviewing and interpreting data.
Systems Organization and Improvement
In order to improve efficiency and quality in their organizations, pediatric hospitalists should:
Engage Hospital Senior Management, Hospital Board of Directors and Medical Staff leadership in creating, implementing, and sustaining short and long term quality improvement goals.
Participate on Quality Improvement committees and seek opportunities to serve as Quality Improvement Officers or Consultants.
Advocate for the necessary information systems and other infrastructure to secure accurate data and assure success in the CQI process.
Copyright © 2010 Society of Hospital Medicine
Child abuse and neglect
Introduction
Child abuse or neglect is the physical, sexual or emotional maltreatment of children, by a caregiver or other adult, resulting in injury or illness. Approximately 1 million children per year are victims of abuse or neglect resulting in nearly 2000 fatalities per year. Pediatric hospitalists provide care for these victims by identifying, assessing, and treating injuries as well as ensuring the safety of these children and others in the household. Pediatric hospitalists fulfill varied roles depending on the local services available, but in all cases work collaboratively with social service agencies and legal authorities in situations of alleged abuse.
Knowledge
Pediatric hospitalists should be able to:
Describe the aspects of the history or physical examination that should prompt an evaluation for child abuse or neglect including specific patterns consistent with abuse such as shaken baby syndrome, malnutrition, specific long bone fracture patterns, skin demarcations, and others.
Identify circumstances that may be associated with an increased risk of child abuse such as poverty, family/caregiver stress and isolation, intimate partner violence, special needs children and substance abuse.
Discuss the utility of radiological and laboratory studies in the evaluation of suspected child abuse.
List and discuss different medical diseases which may mimic the presentation of child abuse and neglect.
Discuss cultural differences in the treatment of ill children that may cause unusual physical examination findings such as coining.
Discuss the relationship between developmental stages of children and how these are related to accidental injuries.
Identify the requirements for and steps involved in mandatory reporting of suspected child abuse to the local or state child protective agencies.
Describe state and local statutes defining child maltreatment.
Explain the local processes involved in a hospital admission including methods and timing of consultations and screening exams for both physical abuse and sexual assault cases.
Describe the role of various consultants who may be involved in an evaluation such as ophthalmology, radiology, hematology, genetics, neurology, surgery, neurosurgery, child abuse and protection team, trauma team, social services, child protective services, psychiatry and others.
Discuss the importance of proper, objective written documentation in the medical record.
Explain the role of pediatric hospitalists in providing testimony in court either as attending of record or as expert witness, as appropriate for the local context and training.
List local community resources available for the family/caregiver and abused children such as foster care, receiving homes, support groups, safe houses, parenting courses, and others.
Skills
Pediatric hospitalists should be able to:
Document and collect evidence in collaboration with abuse experts as appropriate for the local context.
Recognize physical examination findings that are suggestive of child abuse or neglect.
Evaluate children who are failing to thrive for psychosocial contributors to the malnutrition.
Recognize abuse in children presenting with injury and unexplained symptoms such as Apparent Life Threatening Event.
Recognize fracture types on radiographs that are suggestive of child abuse.
Differentiate bruises, burns, and skin demarcations typically seen in abuse from those seen in unintentional injury such as accidental trauma, childhood rashes, or use of culturally acceptable therapies.
Perform a fundoscopic examination to screen for retinal hemorrhages in children with suspected abusive head trauma.
Access relevant consults effectively and efficiently.
Report suspected abuse promptly and effectively.
Obtain critical tests and imaging efficiently and safely.
Coordinate care with subspecialists, the primary care provider and other services and arrange an appropriate multidisciplinary transition plan for hospital discharge including determination of the location and responsible party to whom the child will be discharged.
Attitudes
Pediatric hospitalists should be able to:
Realize that child abuse occurs in all cultures, ethnicities and socioeconomic classes.
Communicate in a sensitive, empathetic, unbiased, and ethical manner.
Communicate effectively with patients, the family/caregiver, and healthcare providers regarding findings and care plans.
Maintain professionalism when providing assessments of suspected abuse cases to law enforcement or social service agencies.
Collaborate with subspecialists and the primary care provider to ensure coordinated longitudinal care for abused children.
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 evaluation and management for hospitalized children with suspected abuse.
Collaborate with hospital administration and community partners to develop and sustain referral networks between community based practices or hospitals, tertiary referral centers, social service agencies and legal agencies.
Introduction
Child abuse or neglect is the physical, sexual or emotional maltreatment of children, by a caregiver or other adult, resulting in injury or illness. Approximately 1 million children per year are victims of abuse or neglect resulting in nearly 2000 fatalities per year. Pediatric hospitalists provide care for these victims by identifying, assessing, and treating injuries as well as ensuring the safety of these children and others in the household. Pediatric hospitalists fulfill varied roles depending on the local services available, but in all cases work collaboratively with social service agencies and legal authorities in situations of alleged abuse.
Knowledge
Pediatric hospitalists should be able to:
Describe the aspects of the history or physical examination that should prompt an evaluation for child abuse or neglect including specific patterns consistent with abuse such as shaken baby syndrome, malnutrition, specific long bone fracture patterns, skin demarcations, and others.
Identify circumstances that may be associated with an increased risk of child abuse such as poverty, family/caregiver stress and isolation, intimate partner violence, special needs children and substance abuse.
Discuss the utility of radiological and laboratory studies in the evaluation of suspected child abuse.
List and discuss different medical diseases which may mimic the presentation of child abuse and neglect.
Discuss cultural differences in the treatment of ill children that may cause unusual physical examination findings such as coining.
Discuss the relationship between developmental stages of children and how these are related to accidental injuries.
Identify the requirements for and steps involved in mandatory reporting of suspected child abuse to the local or state child protective agencies.
Describe state and local statutes defining child maltreatment.
Explain the local processes involved in a hospital admission including methods and timing of consultations and screening exams for both physical abuse and sexual assault cases.
Describe the role of various consultants who may be involved in an evaluation such as ophthalmology, radiology, hematology, genetics, neurology, surgery, neurosurgery, child abuse and protection team, trauma team, social services, child protective services, psychiatry and others.
Discuss the importance of proper, objective written documentation in the medical record.
Explain the role of pediatric hospitalists in providing testimony in court either as attending of record or as expert witness, as appropriate for the local context and training.
List local community resources available for the family/caregiver and abused children such as foster care, receiving homes, support groups, safe houses, parenting courses, and others.
Skills
Pediatric hospitalists should be able to:
Document and collect evidence in collaboration with abuse experts as appropriate for the local context.
Recognize physical examination findings that are suggestive of child abuse or neglect.
Evaluate children who are failing to thrive for psychosocial contributors to the malnutrition.
Recognize abuse in children presenting with injury and unexplained symptoms such as Apparent Life Threatening Event.
Recognize fracture types on radiographs that are suggestive of child abuse.
Differentiate bruises, burns, and skin demarcations typically seen in abuse from those seen in unintentional injury such as accidental trauma, childhood rashes, or use of culturally acceptable therapies.
Perform a fundoscopic examination to screen for retinal hemorrhages in children with suspected abusive head trauma.
Access relevant consults effectively and efficiently.
Report suspected abuse promptly and effectively.
Obtain critical tests and imaging efficiently and safely.
Coordinate care with subspecialists, the primary care provider and other services and arrange an appropriate multidisciplinary transition plan for hospital discharge including determination of the location and responsible party to whom the child will be discharged.
Attitudes
Pediatric hospitalists should be able to:
Realize that child abuse occurs in all cultures, ethnicities and socioeconomic classes.
Communicate in a sensitive, empathetic, unbiased, and ethical manner.
Communicate effectively with patients, the family/caregiver, and healthcare providers regarding findings and care plans.
Maintain professionalism when providing assessments of suspected abuse cases to law enforcement or social service agencies.
Collaborate with subspecialists and the primary care provider to ensure coordinated longitudinal care for abused children.
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 evaluation and management for hospitalized children with suspected abuse.
Collaborate with hospital administration and community partners to develop and sustain referral networks between community based practices or hospitals, tertiary referral centers, social service agencies and legal agencies.
Introduction
Child abuse or neglect is the physical, sexual or emotional maltreatment of children, by a caregiver or other adult, resulting in injury or illness. Approximately 1 million children per year are victims of abuse or neglect resulting in nearly 2000 fatalities per year. Pediatric hospitalists provide care for these victims by identifying, assessing, and treating injuries as well as ensuring the safety of these children and others in the household. Pediatric hospitalists fulfill varied roles depending on the local services available, but in all cases work collaboratively with social service agencies and legal authorities in situations of alleged abuse.
Knowledge
Pediatric hospitalists should be able to:
Describe the aspects of the history or physical examination that should prompt an evaluation for child abuse or neglect including specific patterns consistent with abuse such as shaken baby syndrome, malnutrition, specific long bone fracture patterns, skin demarcations, and others.
Identify circumstances that may be associated with an increased risk of child abuse such as poverty, family/caregiver stress and isolation, intimate partner violence, special needs children and substance abuse.
Discuss the utility of radiological and laboratory studies in the evaluation of suspected child abuse.
List and discuss different medical diseases which may mimic the presentation of child abuse and neglect.
Discuss cultural differences in the treatment of ill children that may cause unusual physical examination findings such as coining.
Discuss the relationship between developmental stages of children and how these are related to accidental injuries.
Identify the requirements for and steps involved in mandatory reporting of suspected child abuse to the local or state child protective agencies.
Describe state and local statutes defining child maltreatment.
Explain the local processes involved in a hospital admission including methods and timing of consultations and screening exams for both physical abuse and sexual assault cases.
Describe the role of various consultants who may be involved in an evaluation such as ophthalmology, radiology, hematology, genetics, neurology, surgery, neurosurgery, child abuse and protection team, trauma team, social services, child protective services, psychiatry and others.
Discuss the importance of proper, objective written documentation in the medical record.
Explain the role of pediatric hospitalists in providing testimony in court either as attending of record or as expert witness, as appropriate for the local context and training.
List local community resources available for the family/caregiver and abused children such as foster care, receiving homes, support groups, safe houses, parenting courses, and others.
Skills
Pediatric hospitalists should be able to:
Document and collect evidence in collaboration with abuse experts as appropriate for the local context.
Recognize physical examination findings that are suggestive of child abuse or neglect.
Evaluate children who are failing to thrive for psychosocial contributors to the malnutrition.
Recognize abuse in children presenting with injury and unexplained symptoms such as Apparent Life Threatening Event.
Recognize fracture types on radiographs that are suggestive of child abuse.
Differentiate bruises, burns, and skin demarcations typically seen in abuse from those seen in unintentional injury such as accidental trauma, childhood rashes, or use of culturally acceptable therapies.
Perform a fundoscopic examination to screen for retinal hemorrhages in children with suspected abusive head trauma.
Access relevant consults effectively and efficiently.
Report suspected abuse promptly and effectively.
Obtain critical tests and imaging efficiently and safely.
Coordinate care with subspecialists, the primary care provider and other services and arrange an appropriate multidisciplinary transition plan for hospital discharge including determination of the location and responsible party to whom the child will be discharged.
Attitudes
Pediatric hospitalists should be able to:
Realize that child abuse occurs in all cultures, ethnicities and socioeconomic classes.
Communicate in a sensitive, empathetic, unbiased, and ethical manner.
Communicate effectively with patients, the family/caregiver, and healthcare providers regarding findings and care plans.
Maintain professionalism when providing assessments of suspected abuse cases to law enforcement or social service agencies.
Collaborate with subspecialists and the primary care provider to ensure coordinated longitudinal care for abused children.
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 evaluation and management for hospitalized children with suspected abuse.
Collaborate with hospital administration and community partners to develop and sustain referral networks between community based practices or hospitals, tertiary referral centers, social service agencies and legal agencies.
Copyright © 2010 Society of Hospital Medicine
Legal issues / risk management
Introduction
Risk Management is a discipline commonly perceived to be the domain of the institutional personnel and committees who are called upon to administer the aftermath of adverse events. However, consequence management is far from the most effective utilization of such resources, as they are most efficiently and ethically deployed in preventive programs. Risk management therefore prospectively draws upon the disciplines of law, patient safety, quality improvement, systems management, ethics, and human resources in addition to medicine, in an effort to eliminate or ameliorate the undesirable consequences of delivering healthcare services.
Knowledge
Pediatric hospitalists should be able to:
Summarize the regulatory and legal stipulations that may impact pediatric hospitalists' contracting and practice including:
Anti‐kickback regulations (Stark Rules)
Anti‐trust regulations (Sherman Act)
Billing rules, coding for services, collections (Fraud and Abuse regulations)
Transfer / transport of patients (Emergency Medical Treatment and Active Labor Act (EMTALA))
Utilization review and managed care issues
Describe the behavioral and physical characteristics of the impaired practitioner, including fatigue, substance abuse, and disruptive behavior.
Identify the role of behavior and attitudes in generating patient and family/caregiver complaints.
Explain the role of formal intervention programs for impaired practitioners.
State the responsibilities of state medical licensing boards and the Drug Enforcement Agency.
Summarize the role of the Hospital Medical Staff in granting clinical privileges and initiating disciplinary actions.
Define the role of the National Practitioner Data Bank.
List responsibilities associated with maintaining malpractice insurance, including documentation and disclosure requirements).
Explain the legal definition of negligence.
Define the terms assent and consent, and describe the circumstances in which informed assent or consent is needed.
Explain the role of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Rule in maintaining patient confidentiality.
Compare and contrast the malpractice risk in healthcare environments with and without trainees.
Give an example of legal issues which can arise in various clinical scenarios such as end of life care, no code discussions (do‐not‐resuscitate or allow‐natural‐death) organ donation, guardianship, and newborn resuscitation.
Describe the role of pediatric hospitalists in recognizing and reporting family violence (child, spouse and elder abuse).
Skills
Pediatric hospitalists should be able to:
Obtain informed assent and/or consent from patients and/or the family/caregiver.
Disclose medical errors clearly, concisely and completely to patients and the family/caregiver.
Accurately communicate in difficult situations and when delivering sensitive information, with compassion and a professional attitude.
Effectively support and communicate end‐of‐life decisions and planning.
Consistently practice patient and family centered care by educating and empowering patients and the family/caregiver thereby enhancing safe delivery of healthcare.
Transfer patient information concisely and precisely to other healthcare providers during all transitions of care.
Prescribe treatments safely, using safe medication prescribing practices.
Consistently document in the medical record with accuracy and appropriate detail.
Attitudes
Pediatric hospitalists should be able to:
Role model professional behavior.
Respond to complaints in a compassionate and sensitive manner.
Seek opportunities to learn and practice risk reduction strategies (such as failure modes and effects analysis (FMEA) and others).
Engage trainees in discussions on the importance of communication and documentation.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Engage in organizational risk management efforts, and promote risk prevention by active participation in appropriate hospital committees.
Advocate for healthcare information systems that enhance ease and accuracy of documentation and prescribing.
Encourage and support efforts to create a comprehensive risk reduction program encompassing education for hospital staff, medical staff, and trainees.
Introduction
Risk Management is a discipline commonly perceived to be the domain of the institutional personnel and committees who are called upon to administer the aftermath of adverse events. However, consequence management is far from the most effective utilization of such resources, as they are most efficiently and ethically deployed in preventive programs. Risk management therefore prospectively draws upon the disciplines of law, patient safety, quality improvement, systems management, ethics, and human resources in addition to medicine, in an effort to eliminate or ameliorate the undesirable consequences of delivering healthcare services.
Knowledge
Pediatric hospitalists should be able to:
Summarize the regulatory and legal stipulations that may impact pediatric hospitalists' contracting and practice including:
Anti‐kickback regulations (Stark Rules)
Anti‐trust regulations (Sherman Act)
Billing rules, coding for services, collections (Fraud and Abuse regulations)
Transfer / transport of patients (Emergency Medical Treatment and Active Labor Act (EMTALA))
Utilization review and managed care issues
Describe the behavioral and physical characteristics of the impaired practitioner, including fatigue, substance abuse, and disruptive behavior.
Identify the role of behavior and attitudes in generating patient and family/caregiver complaints.
Explain the role of formal intervention programs for impaired practitioners.
State the responsibilities of state medical licensing boards and the Drug Enforcement Agency.
Summarize the role of the Hospital Medical Staff in granting clinical privileges and initiating disciplinary actions.
Define the role of the National Practitioner Data Bank.
List responsibilities associated with maintaining malpractice insurance, including documentation and disclosure requirements).
Explain the legal definition of negligence.
Define the terms assent and consent, and describe the circumstances in which informed assent or consent is needed.
Explain the role of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Rule in maintaining patient confidentiality.
Compare and contrast the malpractice risk in healthcare environments with and without trainees.
Give an example of legal issues which can arise in various clinical scenarios such as end of life care, no code discussions (do‐not‐resuscitate or allow‐natural‐death) organ donation, guardianship, and newborn resuscitation.
Describe the role of pediatric hospitalists in recognizing and reporting family violence (child, spouse and elder abuse).
Skills
Pediatric hospitalists should be able to:
Obtain informed assent and/or consent from patients and/or the family/caregiver.
Disclose medical errors clearly, concisely and completely to patients and the family/caregiver.
Accurately communicate in difficult situations and when delivering sensitive information, with compassion and a professional attitude.
Effectively support and communicate end‐of‐life decisions and planning.
Consistently practice patient and family centered care by educating and empowering patients and the family/caregiver thereby enhancing safe delivery of healthcare.
Transfer patient information concisely and precisely to other healthcare providers during all transitions of care.
Prescribe treatments safely, using safe medication prescribing practices.
Consistently document in the medical record with accuracy and appropriate detail.
Attitudes
Pediatric hospitalists should be able to:
Role model professional behavior.
Respond to complaints in a compassionate and sensitive manner.
Seek opportunities to learn and practice risk reduction strategies (such as failure modes and effects analysis (FMEA) and others).
Engage trainees in discussions on the importance of communication and documentation.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Engage in organizational risk management efforts, and promote risk prevention by active participation in appropriate hospital committees.
Advocate for healthcare information systems that enhance ease and accuracy of documentation and prescribing.
Encourage and support efforts to create a comprehensive risk reduction program encompassing education for hospital staff, medical staff, and trainees.
Introduction
Risk Management is a discipline commonly perceived to be the domain of the institutional personnel and committees who are called upon to administer the aftermath of adverse events. However, consequence management is far from the most effective utilization of such resources, as they are most efficiently and ethically deployed in preventive programs. Risk management therefore prospectively draws upon the disciplines of law, patient safety, quality improvement, systems management, ethics, and human resources in addition to medicine, in an effort to eliminate or ameliorate the undesirable consequences of delivering healthcare services.
Knowledge
Pediatric hospitalists should be able to:
Summarize the regulatory and legal stipulations that may impact pediatric hospitalists' contracting and practice including:
Anti‐kickback regulations (Stark Rules)
Anti‐trust regulations (Sherman Act)
Billing rules, coding for services, collections (Fraud and Abuse regulations)
Transfer / transport of patients (Emergency Medical Treatment and Active Labor Act (EMTALA))
Utilization review and managed care issues
Describe the behavioral and physical characteristics of the impaired practitioner, including fatigue, substance abuse, and disruptive behavior.
Identify the role of behavior and attitudes in generating patient and family/caregiver complaints.
Explain the role of formal intervention programs for impaired practitioners.
State the responsibilities of state medical licensing boards and the Drug Enforcement Agency.
Summarize the role of the Hospital Medical Staff in granting clinical privileges and initiating disciplinary actions.
Define the role of the National Practitioner Data Bank.
List responsibilities associated with maintaining malpractice insurance, including documentation and disclosure requirements).
Explain the legal definition of negligence.
Define the terms assent and consent, and describe the circumstances in which informed assent or consent is needed.
Explain the role of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Rule in maintaining patient confidentiality.
Compare and contrast the malpractice risk in healthcare environments with and without trainees.
Give an example of legal issues which can arise in various clinical scenarios such as end of life care, no code discussions (do‐not‐resuscitate or allow‐natural‐death) organ donation, guardianship, and newborn resuscitation.
Describe the role of pediatric hospitalists in recognizing and reporting family violence (child, spouse and elder abuse).
Skills
Pediatric hospitalists should be able to:
Obtain informed assent and/or consent from patients and/or the family/caregiver.
Disclose medical errors clearly, concisely and completely to patients and the family/caregiver.
Accurately communicate in difficult situations and when delivering sensitive information, with compassion and a professional attitude.
Effectively support and communicate end‐of‐life decisions and planning.
Consistently practice patient and family centered care by educating and empowering patients and the family/caregiver thereby enhancing safe delivery of healthcare.
Transfer patient information concisely and precisely to other healthcare providers during all transitions of care.
Prescribe treatments safely, using safe medication prescribing practices.
Consistently document in the medical record with accuracy and appropriate detail.
Attitudes
Pediatric hospitalists should be able to:
Role model professional behavior.
Respond to complaints in a compassionate and sensitive manner.
Seek opportunities to learn and practice risk reduction strategies (such as failure modes and effects analysis (FMEA) and others).
Engage trainees in discussions on the importance of communication and documentation.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Engage in organizational risk management efforts, and promote risk prevention by active participation in appropriate hospital committees.
Advocate for healthcare information systems that enhance ease and accuracy of documentation and prescribing.
Encourage and support efforts to create a comprehensive risk reduction program encompassing education for hospital staff, medical staff, and trainees.
Copyright © 2010 Society of Hospital Medicine
Business practices
Introduction
Sound business practices form a foundation for the growth and effective development of pediatric hospital medicine programs. Business practice refers to program development and growth, practice management, contract negotiation, and financial solvency. Pediatric hospitalists require fundamental business skills to enhance individual success, and facilitate growth and stability of groups, divisions, and institutions. Hospitals increasingly need physician leaders with these skills to improve operational efficiency and meet other institutional needs. Pediatric hospitalists must acquire and maintain business skills that support the ability to negotiate and define hospitalist roles within the hospital, expand practices intelligently, anticipate and respond to change, and sustain financial success.
Knowledge
Pediatric hospitalists should be able to:
Explain why clinical practice is a business that needs a sound business plan, professional management, and strategic planning. Discuss the elements of mission and vision statements.
Identify institutional financial power structures and how resources are developed to build and sustain academic and non‐academic programs.
Compare and contrast the basic structure of hospital‐employed and private practice pediatric hospital medicine models.
Define the basic components assessed during the initial planning for a pediatric hospitalist practice, such as baseline and projected census, projected revenue and expenses, and impact on current and future stakeholders.
Articulate the requirements for compliant billing and documenting when collaborating with physician extenders.
Discuss the impact of critical practice variables on creation of an effective and efficient staffing plan, including:
Anticipated census, patient acuity and length of stay
Anticipated revenue streams and volume
Need for night and/or weekend coverage
Physician‐to‐patient ratios
Compare and contrast pediatric hospitalist staffing models, including:
Rounding or patient‐based model
Shift‐based model
List potential sources of non‐clinical responsibilities, such as teaching, committee participation, administrative work, and research. Describe the impact of each on staffing models and revenue.
Distinguish between various pediatric hospitalist compensation structures, including full salary, incentive salary, and case rate models.
Define the Relative Value Unit (RVU) and its utility in tracking revenue and physician compensation.
Discuss the difference between costs versus charges.
Compare and contrast basic billing methods and revenue sources for the provider versus the hospital, and review the effect of payor mix on these.
Articulate the importance of billing and coding compliance as it relates to physician compensation and physician‐hospital contracting.
Identify key elements of compliance monitored by the Office of the Inspector General (OIG) of the Department of Health and Human Services (DHHS).
State the importance of professional credentialing, licensing and liability coverage.
Describe key features of care management organizations, such as capitation, carve‐outs, withholds, case‐, disease‐, and demand‐management and their role in promoting quality of care and cost‐control.
Skills
Pediatric hospitalists should be able to:
Review basic business data including revenue, expenses, staff and marketing costs, and accounts receivable.
Demonstrate basic negotiation skills through role play or attendance at negotiation sessions with third party payors, the institution, department chair, or other contracted entity.
Consistently document in the medical record in a manner that meets expectations for billing and coding and for external certifying agencies.
Effectively utilize a clinical documentation system with an emphasis on:
Efficient, accurate, and complete documentation to support coding and billing
Compliance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA)
Compliance with trainee documentation guidelines, where applicable
Complete coding and billing processes efficiently and accurately.
Participate in group, division, and/or institutional business and finance committees.
Attitudes
Pediatric hospitalists should be able to:
Advocate for a business model that encourages retention of pediatric hospitalists and allows for adequate staffing to support patient safety, and physician wellness.
Role model accountability with regard to billing, coding and business regulations.
Support the business of pediatric hospitalists, by maintaining fiscally awareness and proactively managing stakeholder expectations.
Seek opportunities to acquire basic business skills.
Systems Organization and Improvement
In order to improve efficiency and quality in their organizations, pediatric hospitalists should:
Collaborate with colleagues and business office leaders to make sound group/division business decisions using performance feedback, peer review and quality improvement information.
Engage with hospital administrators on strategic business planning, wherever possible.
Introduction
Sound business practices form a foundation for the growth and effective development of pediatric hospital medicine programs. Business practice refers to program development and growth, practice management, contract negotiation, and financial solvency. Pediatric hospitalists require fundamental business skills to enhance individual success, and facilitate growth and stability of groups, divisions, and institutions. Hospitals increasingly need physician leaders with these skills to improve operational efficiency and meet other institutional needs. Pediatric hospitalists must acquire and maintain business skills that support the ability to negotiate and define hospitalist roles within the hospital, expand practices intelligently, anticipate and respond to change, and sustain financial success.
Knowledge
Pediatric hospitalists should be able to:
Explain why clinical practice is a business that needs a sound business plan, professional management, and strategic planning. Discuss the elements of mission and vision statements.
Identify institutional financial power structures and how resources are developed to build and sustain academic and non‐academic programs.
Compare and contrast the basic structure of hospital‐employed and private practice pediatric hospital medicine models.
Define the basic components assessed during the initial planning for a pediatric hospitalist practice, such as baseline and projected census, projected revenue and expenses, and impact on current and future stakeholders.
Articulate the requirements for compliant billing and documenting when collaborating with physician extenders.
Discuss the impact of critical practice variables on creation of an effective and efficient staffing plan, including:
Anticipated census, patient acuity and length of stay
Anticipated revenue streams and volume
Need for night and/or weekend coverage
Physician‐to‐patient ratios
Compare and contrast pediatric hospitalist staffing models, including:
Rounding or patient‐based model
Shift‐based model
List potential sources of non‐clinical responsibilities, such as teaching, committee participation, administrative work, and research. Describe the impact of each on staffing models and revenue.
Distinguish between various pediatric hospitalist compensation structures, including full salary, incentive salary, and case rate models.
Define the Relative Value Unit (RVU) and its utility in tracking revenue and physician compensation.
Discuss the difference between costs versus charges.
Compare and contrast basic billing methods and revenue sources for the provider versus the hospital, and review the effect of payor mix on these.
Articulate the importance of billing and coding compliance as it relates to physician compensation and physician‐hospital contracting.
Identify key elements of compliance monitored by the Office of the Inspector General (OIG) of the Department of Health and Human Services (DHHS).
State the importance of professional credentialing, licensing and liability coverage.
Describe key features of care management organizations, such as capitation, carve‐outs, withholds, case‐, disease‐, and demand‐management and their role in promoting quality of care and cost‐control.
Skills
Pediatric hospitalists should be able to:
Review basic business data including revenue, expenses, staff and marketing costs, and accounts receivable.
Demonstrate basic negotiation skills through role play or attendance at negotiation sessions with third party payors, the institution, department chair, or other contracted entity.
Consistently document in the medical record in a manner that meets expectations for billing and coding and for external certifying agencies.
Effectively utilize a clinical documentation system with an emphasis on:
Efficient, accurate, and complete documentation to support coding and billing
Compliance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA)
Compliance with trainee documentation guidelines, where applicable
Complete coding and billing processes efficiently and accurately.
Participate in group, division, and/or institutional business and finance committees.
Attitudes
Pediatric hospitalists should be able to:
Advocate for a business model that encourages retention of pediatric hospitalists and allows for adequate staffing to support patient safety, and physician wellness.
Role model accountability with regard to billing, coding and business regulations.
Support the business of pediatric hospitalists, by maintaining fiscally awareness and proactively managing stakeholder expectations.
Seek opportunities to acquire basic business skills.
Systems Organization and Improvement
In order to improve efficiency and quality in their organizations, pediatric hospitalists should:
Collaborate with colleagues and business office leaders to make sound group/division business decisions using performance feedback, peer review and quality improvement information.
Engage with hospital administrators on strategic business planning, wherever possible.
Introduction
Sound business practices form a foundation for the growth and effective development of pediatric hospital medicine programs. Business practice refers to program development and growth, practice management, contract negotiation, and financial solvency. Pediatric hospitalists require fundamental business skills to enhance individual success, and facilitate growth and stability of groups, divisions, and institutions. Hospitals increasingly need physician leaders with these skills to improve operational efficiency and meet other institutional needs. Pediatric hospitalists must acquire and maintain business skills that support the ability to negotiate and define hospitalist roles within the hospital, expand practices intelligently, anticipate and respond to change, and sustain financial success.
Knowledge
Pediatric hospitalists should be able to:
Explain why clinical practice is a business that needs a sound business plan, professional management, and strategic planning. Discuss the elements of mission and vision statements.
Identify institutional financial power structures and how resources are developed to build and sustain academic and non‐academic programs.
Compare and contrast the basic structure of hospital‐employed and private practice pediatric hospital medicine models.
Define the basic components assessed during the initial planning for a pediatric hospitalist practice, such as baseline and projected census, projected revenue and expenses, and impact on current and future stakeholders.
Articulate the requirements for compliant billing and documenting when collaborating with physician extenders.
Discuss the impact of critical practice variables on creation of an effective and efficient staffing plan, including:
Anticipated census, patient acuity and length of stay
Anticipated revenue streams and volume
Need for night and/or weekend coverage
Physician‐to‐patient ratios
Compare and contrast pediatric hospitalist staffing models, including:
Rounding or patient‐based model
Shift‐based model
List potential sources of non‐clinical responsibilities, such as teaching, committee participation, administrative work, and research. Describe the impact of each on staffing models and revenue.
Distinguish between various pediatric hospitalist compensation structures, including full salary, incentive salary, and case rate models.
Define the Relative Value Unit (RVU) and its utility in tracking revenue and physician compensation.
Discuss the difference between costs versus charges.
Compare and contrast basic billing methods and revenue sources for the provider versus the hospital, and review the effect of payor mix on these.
Articulate the importance of billing and coding compliance as it relates to physician compensation and physician‐hospital contracting.
Identify key elements of compliance monitored by the Office of the Inspector General (OIG) of the Department of Health and Human Services (DHHS).
State the importance of professional credentialing, licensing and liability coverage.
Describe key features of care management organizations, such as capitation, carve‐outs, withholds, case‐, disease‐, and demand‐management and their role in promoting quality of care and cost‐control.
Skills
Pediatric hospitalists should be able to:
Review basic business data including revenue, expenses, staff and marketing costs, and accounts receivable.
Demonstrate basic negotiation skills through role play or attendance at negotiation sessions with third party payors, the institution, department chair, or other contracted entity.
Consistently document in the medical record in a manner that meets expectations for billing and coding and for external certifying agencies.
Effectively utilize a clinical documentation system with an emphasis on:
Efficient, accurate, and complete documentation to support coding and billing
Compliance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA)
Compliance with trainee documentation guidelines, where applicable
Complete coding and billing processes efficiently and accurately.
Participate in group, division, and/or institutional business and finance committees.
Attitudes
Pediatric hospitalists should be able to:
Advocate for a business model that encourages retention of pediatric hospitalists and allows for adequate staffing to support patient safety, and physician wellness.
Role model accountability with regard to billing, coding and business regulations.
Support the business of pediatric hospitalists, by maintaining fiscally awareness and proactively managing stakeholder expectations.
Seek opportunities to acquire basic business skills.
Systems Organization and Improvement
In order to improve efficiency and quality in their organizations, pediatric hospitalists should:
Collaborate with colleagues and business office leaders to make sound group/division business decisions using performance feedback, peer review and quality improvement information.
Engage with hospital administrators on strategic business planning, wherever possible.
Copyright © 2010 Society of Hospital Medicine
Bone and joint infections
Introduction
Osteomyelitis is a pyogenic infection of the bone or periosteum, whereas septic arthritis is an infection of the joint space itself. These occur in children as a result of hematogenous spread or local invasion after soft tissue infection or trauma. Either site of infection may represent a medical emergency in children. Bone and joint infections are commonly caused by Staphylococcus aureus, Streptococcal species and Salmonella. These infections can occur at any age, with osteomyelitis occurring in as many as 1 in 5000 children every year. Males are nearly twice as likely to be affected compared to females. Prompt recognition and appropriate treatment are essential to reduce the risk of significant complications including permanent bone or cartilage destruction with life‐long disability. Pediatric hospitalists are often in the best position to render acute inpatient care and coordinate transition to outpatient care to ensure best outcomes.
Knowledge
Pediatric hospitalists should be able to:
Discuss the differential diagnosis of common presenting signs and symptoms of bone and joint infections including swollen joint, limp and bone pain.
Describe the pathophysiology of osteomyelitis including the most common site of infection in a developing bone.
Explain the pathophysiologic mechanisms involved in septic arthritis.
Compare and contrast the varied clinical presentations of bone and soft tissue infections in children of differing ages (infancy to adolescence) and underlying co‐morbidities (such as sickle cell disease, immunosuppressed, and others).
Identify indications for admission to the hospital for children with suspected osteomyelitis and septic arthritis and goals for therapy during the inpatient stay.
Classify the most likely pathogens based on age, underlying risk factors, and exposures and list appropriate antimicrobial agents for each.
State relative local antimicrobial resistance rates for the most common organisms and explain the importance of these in prescribing therapy.
Describe the relative advantages, disadvantages, and local availability of commonly used laboratory (such as C ‐ reactive protein, blood cultures, bone aspirate and other) and radiologic (such as plain film, computed tomography, bone scan, magnetic resonance imaging and other) modalities in the evaluation of bone and joint infections.
Discuss the role of various services in pain management, such as child life and the acute pain service.
State the available home care services for children in the area served and explain the role of home care in discharge decision making.
Define the role of the orthopedist and infectious diseases subspecialists in consultation, co‐management, and follow‐up care.
Compare and contrast the expertise, skill sets, and availability of orthopedists with pediatric orthopedists in the local area and list criteria for transfer to a tertiary care center attending to local context.
List the components of an efficient and effective hospital discharge, including documentation of appropriate clinical improvement, discharge planning completed, antimicrobial therapy duration and monitoring determined, and others.
Identify aspects of diagnosis and treatment that may impact prognosis.
Skills
Pediatric hospitalists should be able to:
Correctly diagnose osteomyelitis or septic arthritis by efficiently performing an accurate history and physical examination.
Order appropriate diagnostic studies and correctly interpret study results.
Develop a cost effective diagnostic work‐up for bone and joint infections, including laboratory and radiographic testing.
Manage pain for children with bone and joint infections.
Consult appropriate subspecialists in a timely and effective manner.
Demonstrate competence in placing parenterally inserted central catheters (PICC) or efficiently obtain services for PICC placement.
Efficiently access and arrange for pediatric home care services as appropriate.
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, the family/caregiver and healthcare providers regarding findings and care plans.
Assume responsibility for care as the primary attending or in collaboration with the orthopedic team.
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 bone and joint infections.
Work with hospital administration to recruit a multidisciplinary team in the care of children with bone and joint infections that may include nursing, social work, physical therapy, pharmacy and care coordinators.
Assist in creating systems to evaluate and improve pain management for children hospitalized with bone and joint infections.
Lead, coordinate or participate in efforts to increase pediatric‐specific community health care resources that allow for an efficient transition to outpatient therapy and management after inpatient goals are achieved.
Introduction
Osteomyelitis is a pyogenic infection of the bone or periosteum, whereas septic arthritis is an infection of the joint space itself. These occur in children as a result of hematogenous spread or local invasion after soft tissue infection or trauma. Either site of infection may represent a medical emergency in children. Bone and joint infections are commonly caused by Staphylococcus aureus, Streptococcal species and Salmonella. These infections can occur at any age, with osteomyelitis occurring in as many as 1 in 5000 children every year. Males are nearly twice as likely to be affected compared to females. Prompt recognition and appropriate treatment are essential to reduce the risk of significant complications including permanent bone or cartilage destruction with life‐long disability. Pediatric hospitalists are often in the best position to render acute inpatient care and coordinate transition to outpatient care to ensure best outcomes.
Knowledge
Pediatric hospitalists should be able to:
Discuss the differential diagnosis of common presenting signs and symptoms of bone and joint infections including swollen joint, limp and bone pain.
Describe the pathophysiology of osteomyelitis including the most common site of infection in a developing bone.
Explain the pathophysiologic mechanisms involved in septic arthritis.
Compare and contrast the varied clinical presentations of bone and soft tissue infections in children of differing ages (infancy to adolescence) and underlying co‐morbidities (such as sickle cell disease, immunosuppressed, and others).
Identify indications for admission to the hospital for children with suspected osteomyelitis and septic arthritis and goals for therapy during the inpatient stay.
Classify the most likely pathogens based on age, underlying risk factors, and exposures and list appropriate antimicrobial agents for each.
State relative local antimicrobial resistance rates for the most common organisms and explain the importance of these in prescribing therapy.
Describe the relative advantages, disadvantages, and local availability of commonly used laboratory (such as C ‐ reactive protein, blood cultures, bone aspirate and other) and radiologic (such as plain film, computed tomography, bone scan, magnetic resonance imaging and other) modalities in the evaluation of bone and joint infections.
Discuss the role of various services in pain management, such as child life and the acute pain service.
State the available home care services for children in the area served and explain the role of home care in discharge decision making.
Define the role of the orthopedist and infectious diseases subspecialists in consultation, co‐management, and follow‐up care.
Compare and contrast the expertise, skill sets, and availability of orthopedists with pediatric orthopedists in the local area and list criteria for transfer to a tertiary care center attending to local context.
List the components of an efficient and effective hospital discharge, including documentation of appropriate clinical improvement, discharge planning completed, antimicrobial therapy duration and monitoring determined, and others.
Identify aspects of diagnosis and treatment that may impact prognosis.
Skills
Pediatric hospitalists should be able to:
Correctly diagnose osteomyelitis or septic arthritis by efficiently performing an accurate history and physical examination.
Order appropriate diagnostic studies and correctly interpret study results.
Develop a cost effective diagnostic work‐up for bone and joint infections, including laboratory and radiographic testing.
Manage pain for children with bone and joint infections.
Consult appropriate subspecialists in a timely and effective manner.
Demonstrate competence in placing parenterally inserted central catheters (PICC) or efficiently obtain services for PICC placement.
Efficiently access and arrange for pediatric home care services as appropriate.
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, the family/caregiver and healthcare providers regarding findings and care plans.
Assume responsibility for care as the primary attending or in collaboration with the orthopedic team.
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 bone and joint infections.
Work with hospital administration to recruit a multidisciplinary team in the care of children with bone and joint infections that may include nursing, social work, physical therapy, pharmacy and care coordinators.
Assist in creating systems to evaluate and improve pain management for children hospitalized with bone and joint infections.
Lead, coordinate or participate in efforts to increase pediatric‐specific community health care resources that allow for an efficient transition to outpatient therapy and management after inpatient goals are achieved.
Introduction
Osteomyelitis is a pyogenic infection of the bone or periosteum, whereas septic arthritis is an infection of the joint space itself. These occur in children as a result of hematogenous spread or local invasion after soft tissue infection or trauma. Either site of infection may represent a medical emergency in children. Bone and joint infections are commonly caused by Staphylococcus aureus, Streptococcal species and Salmonella. These infections can occur at any age, with osteomyelitis occurring in as many as 1 in 5000 children every year. Males are nearly twice as likely to be affected compared to females. Prompt recognition and appropriate treatment are essential to reduce the risk of significant complications including permanent bone or cartilage destruction with life‐long disability. Pediatric hospitalists are often in the best position to render acute inpatient care and coordinate transition to outpatient care to ensure best outcomes.
Knowledge
Pediatric hospitalists should be able to:
Discuss the differential diagnosis of common presenting signs and symptoms of bone and joint infections including swollen joint, limp and bone pain.
Describe the pathophysiology of osteomyelitis including the most common site of infection in a developing bone.
Explain the pathophysiologic mechanisms involved in septic arthritis.
Compare and contrast the varied clinical presentations of bone and soft tissue infections in children of differing ages (infancy to adolescence) and underlying co‐morbidities (such as sickle cell disease, immunosuppressed, and others).
Identify indications for admission to the hospital for children with suspected osteomyelitis and septic arthritis and goals for therapy during the inpatient stay.
Classify the most likely pathogens based on age, underlying risk factors, and exposures and list appropriate antimicrobial agents for each.
State relative local antimicrobial resistance rates for the most common organisms and explain the importance of these in prescribing therapy.
Describe the relative advantages, disadvantages, and local availability of commonly used laboratory (such as C ‐ reactive protein, blood cultures, bone aspirate and other) and radiologic (such as plain film, computed tomography, bone scan, magnetic resonance imaging and other) modalities in the evaluation of bone and joint infections.
Discuss the role of various services in pain management, such as child life and the acute pain service.
State the available home care services for children in the area served and explain the role of home care in discharge decision making.
Define the role of the orthopedist and infectious diseases subspecialists in consultation, co‐management, and follow‐up care.
Compare and contrast the expertise, skill sets, and availability of orthopedists with pediatric orthopedists in the local area and list criteria for transfer to a tertiary care center attending to local context.
List the components of an efficient and effective hospital discharge, including documentation of appropriate clinical improvement, discharge planning completed, antimicrobial therapy duration and monitoring determined, and others.
Identify aspects of diagnosis and treatment that may impact prognosis.
Skills
Pediatric hospitalists should be able to:
Correctly diagnose osteomyelitis or septic arthritis by efficiently performing an accurate history and physical examination.
Order appropriate diagnostic studies and correctly interpret study results.
Develop a cost effective diagnostic work‐up for bone and joint infections, including laboratory and radiographic testing.
Manage pain for children with bone and joint infections.
Consult appropriate subspecialists in a timely and effective manner.
Demonstrate competence in placing parenterally inserted central catheters (PICC) or efficiently obtain services for PICC placement.
Efficiently access and arrange for pediatric home care services as appropriate.
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, the family/caregiver and healthcare providers regarding findings and care plans.
Assume responsibility for care as the primary attending or in collaboration with the orthopedic team.
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 bone and joint infections.
Work with hospital administration to recruit a multidisciplinary team in the care of children with bone and joint infections that may include nursing, social work, physical therapy, pharmacy and care coordinators.
Assist in creating systems to evaluate and improve pain management for children hospitalized with bone and joint infections.
Lead, coordinate or participate in efforts to increase pediatric‐specific community health care resources that allow for an efficient transition to outpatient therapy and management after inpatient goals are achieved.
Copyright © 2010 Society of Hospital Medicine
Education
Introduction
Pediatric hospitalists can serve many roles in education, from educating hospital staff, trainees (medical students, residents, and fellows), community clinicians and organizations and colleagues, to investing in self‐education. Many hospitalists derive their academic identity from their pivotal role in teaching trainees or ancillary staff on the hospital wards and in directing training programs. Training future hospitalists and directing continuing medical education programs to enable current hospitalists to update their knowledge and skills are educational opportunities which are emerging as core competencies for the field are defined. Competencies listed below should be addressed in the context of the specific learner‐educator environment.
Knowledge
Pediatric hospitalists should be able to:
Discuss how the principles of adult learning theory, such as those listed below, can be used in leading daily learning activities.
Assessment of learning needs
Case‐based approach building on the learner's previous experiences or encounters
Reflection
Recognition of the teachable moment
Active learning
Provide an effective learning environment
Self‐directed learning
Modeling
Establish learning goals
Describe one's own preferred teaching and learning style and discuss how this may affect learners with different learning styles.
Identify the steps involved in designing a learning activity, curriculum or program which include:
Conduct a needs assessment to determine learner needs
Write competency‐based goals and objectives based upon learner needs to define what is to be accomplished.
Define and secure resources (personnel, readings, handouts, computer programs, and time)
Actively involve learners in attaining competencies
Evaluate the learners' attainment of competencies
Evaluate the effectiveness of the activity, curriculum or program
Define competencies, performance indicators, goals and objectives, and explain their role in the evaluation of physicians.
Describe the pediatric competencies currently required by regulatory agencies such as the Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Pediatrics (ABP). Explain why a continuum of competencies throughout a professional career is required, and illustrate the benefits and challenges of this expectation.
Give illustrative examples of resident performance that fall within each of the six mandated ACGME competency domains: patient care, medical knowledge, practice‐based learning and improvement, interpersonal skills and communications, professionalism, and systems‐based practice.
List specific examples of how pediatric hospitalists can educate to each of the six core competencies, attending to the role on the ward and in the larger healthcare system.
Explain how learners benefit from knowing their learning goals at the start of an educational experience.
Compare the strengths and weaknesses of the following evaluation methods: oral exams, written tests, global evaluations, direct observations with checklists, and multi‐source (360 degree) evaluations.
Compare and contrast formative feedback with summative evaluation.
Describe the typical effects of evaluation on the motivation and learning priorities of both medical students and residents.
Identify how key concepts of evidence‐based medicine literature review should be used to create a plan of evaluation and management for patients.
List resources and activities for continuous learning to maintain current knowledge and skills.
Skills
Pediatric hospitalists should be able to:
Orient trainees to inpatient ward rotation expectations, including learning goals and objectives, patient care and team responsibilities, systems, policies and procedures for the rotation.
Identify the educational objectives and the learner's educational needs in various settings. Use this information to direct selection of content and teaching methods.
Demonstrate efficient and flexible use of time when teaching, adapting the mix of teaching and independent learning activities to optimize use of the time available.
Develop a repertoire of teaching and supervision methods that enhance a learner's knowledge base, clinical skills, and attitudes/behaviors, including:
Bedside teaching
Teaching during work rounds
Lectures or case‐based discussions using multimedia presentation methods
Teaching a specific skill or procedure
Affirm competency when learner masters a skill
Role modeling for learners, with articulation of thought process
Written instruction
Provide frequent, effective feedback based upon direct observation of trainee's clinical, communication, and technical skills and professionalism.
Teach effectively in large group settings, such as hospital or community setting conferences.
Teach effectively in small groups using a case‐based format.
Use different types of questioning (broadening, justifying, hypothetical, and alternative)
Address learning needs of trainees of different levels of experience
Teach patients and the family/caregiver about the diagnosis, planned investigation, management plan and prognosis in an interactive, family centered manner.
Attitudes
Pediatric hospitalists should be able to:
Promote a climate of continuous learning by acknowledging one's own knowledge gaps and prompting learners to teach each other.
Model effective and empathetic communication with patients and the family/caregiver when educating.
Encourage trainees to be self‐directed and to learn independently.
Model professional behavior by being prompt, prepared, available, and approachable in educational efforts.
Build and maintain teamwork by providing reinforcing as well as corrective feedback.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Partner with training programs to create, maintain, and implement inpatient hospital medicine education.
Work with hospital administrators to maintain adequate trainee supervision to ensure patient safety, while encouraging development of autonomous practice.
Through educational efforts, promote quality improvement, patient safety, cost effective care, evidence based medicine and effective communication around inpatient pediatric care.
Integrate and explain the rationale behind established clinical pathways and prompt trainees to use them consistently.
Address the balance of teaching and patient care responsibilities with hospital administration and training program directors to maximize the effectiveness of both.
Collaborate with hospital administration to ensure adequate teaching facilities.
Introduction
Pediatric hospitalists can serve many roles in education, from educating hospital staff, trainees (medical students, residents, and fellows), community clinicians and organizations and colleagues, to investing in self‐education. Many hospitalists derive their academic identity from their pivotal role in teaching trainees or ancillary staff on the hospital wards and in directing training programs. Training future hospitalists and directing continuing medical education programs to enable current hospitalists to update their knowledge and skills are educational opportunities which are emerging as core competencies for the field are defined. Competencies listed below should be addressed in the context of the specific learner‐educator environment.
Knowledge
Pediatric hospitalists should be able to:
Discuss how the principles of adult learning theory, such as those listed below, can be used in leading daily learning activities.
Assessment of learning needs
Case‐based approach building on the learner's previous experiences or encounters
Reflection
Recognition of the teachable moment
Active learning
Provide an effective learning environment
Self‐directed learning
Modeling
Establish learning goals
Describe one's own preferred teaching and learning style and discuss how this may affect learners with different learning styles.
Identify the steps involved in designing a learning activity, curriculum or program which include:
Conduct a needs assessment to determine learner needs
Write competency‐based goals and objectives based upon learner needs to define what is to be accomplished.
Define and secure resources (personnel, readings, handouts, computer programs, and time)
Actively involve learners in attaining competencies
Evaluate the learners' attainment of competencies
Evaluate the effectiveness of the activity, curriculum or program
Define competencies, performance indicators, goals and objectives, and explain their role in the evaluation of physicians.
Describe the pediatric competencies currently required by regulatory agencies such as the Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Pediatrics (ABP). Explain why a continuum of competencies throughout a professional career is required, and illustrate the benefits and challenges of this expectation.
Give illustrative examples of resident performance that fall within each of the six mandated ACGME competency domains: patient care, medical knowledge, practice‐based learning and improvement, interpersonal skills and communications, professionalism, and systems‐based practice.
List specific examples of how pediatric hospitalists can educate to each of the six core competencies, attending to the role on the ward and in the larger healthcare system.
Explain how learners benefit from knowing their learning goals at the start of an educational experience.
Compare the strengths and weaknesses of the following evaluation methods: oral exams, written tests, global evaluations, direct observations with checklists, and multi‐source (360 degree) evaluations.
Compare and contrast formative feedback with summative evaluation.
Describe the typical effects of evaluation on the motivation and learning priorities of both medical students and residents.
Identify how key concepts of evidence‐based medicine literature review should be used to create a plan of evaluation and management for patients.
List resources and activities for continuous learning to maintain current knowledge and skills.
Skills
Pediatric hospitalists should be able to:
Orient trainees to inpatient ward rotation expectations, including learning goals and objectives, patient care and team responsibilities, systems, policies and procedures for the rotation.
Identify the educational objectives and the learner's educational needs in various settings. Use this information to direct selection of content and teaching methods.
Demonstrate efficient and flexible use of time when teaching, adapting the mix of teaching and independent learning activities to optimize use of the time available.
Develop a repertoire of teaching and supervision methods that enhance a learner's knowledge base, clinical skills, and attitudes/behaviors, including:
Bedside teaching
Teaching during work rounds
Lectures or case‐based discussions using multimedia presentation methods
Teaching a specific skill or procedure
Affirm competency when learner masters a skill
Role modeling for learners, with articulation of thought process
Written instruction
Provide frequent, effective feedback based upon direct observation of trainee's clinical, communication, and technical skills and professionalism.
Teach effectively in large group settings, such as hospital or community setting conferences.
Teach effectively in small groups using a case‐based format.
Use different types of questioning (broadening, justifying, hypothetical, and alternative)
Address learning needs of trainees of different levels of experience
Teach patients and the family/caregiver about the diagnosis, planned investigation, management plan and prognosis in an interactive, family centered manner.
Attitudes
Pediatric hospitalists should be able to:
Promote a climate of continuous learning by acknowledging one's own knowledge gaps and prompting learners to teach each other.
Model effective and empathetic communication with patients and the family/caregiver when educating.
Encourage trainees to be self‐directed and to learn independently.
Model professional behavior by being prompt, prepared, available, and approachable in educational efforts.
Build and maintain teamwork by providing reinforcing as well as corrective feedback.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Partner with training programs to create, maintain, and implement inpatient hospital medicine education.
Work with hospital administrators to maintain adequate trainee supervision to ensure patient safety, while encouraging development of autonomous practice.
Through educational efforts, promote quality improvement, patient safety, cost effective care, evidence based medicine and effective communication around inpatient pediatric care.
Integrate and explain the rationale behind established clinical pathways and prompt trainees to use them consistently.
Address the balance of teaching and patient care responsibilities with hospital administration and training program directors to maximize the effectiveness of both.
Collaborate with hospital administration to ensure adequate teaching facilities.
Introduction
Pediatric hospitalists can serve many roles in education, from educating hospital staff, trainees (medical students, residents, and fellows), community clinicians and organizations and colleagues, to investing in self‐education. Many hospitalists derive their academic identity from their pivotal role in teaching trainees or ancillary staff on the hospital wards and in directing training programs. Training future hospitalists and directing continuing medical education programs to enable current hospitalists to update their knowledge and skills are educational opportunities which are emerging as core competencies for the field are defined. Competencies listed below should be addressed in the context of the specific learner‐educator environment.
Knowledge
Pediatric hospitalists should be able to:
Discuss how the principles of adult learning theory, such as those listed below, can be used in leading daily learning activities.
Assessment of learning needs
Case‐based approach building on the learner's previous experiences or encounters
Reflection
Recognition of the teachable moment
Active learning
Provide an effective learning environment
Self‐directed learning
Modeling
Establish learning goals
Describe one's own preferred teaching and learning style and discuss how this may affect learners with different learning styles.
Identify the steps involved in designing a learning activity, curriculum or program which include:
Conduct a needs assessment to determine learner needs
Write competency‐based goals and objectives based upon learner needs to define what is to be accomplished.
Define and secure resources (personnel, readings, handouts, computer programs, and time)
Actively involve learners in attaining competencies
Evaluate the learners' attainment of competencies
Evaluate the effectiveness of the activity, curriculum or program
Define competencies, performance indicators, goals and objectives, and explain their role in the evaluation of physicians.
Describe the pediatric competencies currently required by regulatory agencies such as the Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Pediatrics (ABP). Explain why a continuum of competencies throughout a professional career is required, and illustrate the benefits and challenges of this expectation.
Give illustrative examples of resident performance that fall within each of the six mandated ACGME competency domains: patient care, medical knowledge, practice‐based learning and improvement, interpersonal skills and communications, professionalism, and systems‐based practice.
List specific examples of how pediatric hospitalists can educate to each of the six core competencies, attending to the role on the ward and in the larger healthcare system.
Explain how learners benefit from knowing their learning goals at the start of an educational experience.
Compare the strengths and weaknesses of the following evaluation methods: oral exams, written tests, global evaluations, direct observations with checklists, and multi‐source (360 degree) evaluations.
Compare and contrast formative feedback with summative evaluation.
Describe the typical effects of evaluation on the motivation and learning priorities of both medical students and residents.
Identify how key concepts of evidence‐based medicine literature review should be used to create a plan of evaluation and management for patients.
List resources and activities for continuous learning to maintain current knowledge and skills.
Skills
Pediatric hospitalists should be able to:
Orient trainees to inpatient ward rotation expectations, including learning goals and objectives, patient care and team responsibilities, systems, policies and procedures for the rotation.
Identify the educational objectives and the learner's educational needs in various settings. Use this information to direct selection of content and teaching methods.
Demonstrate efficient and flexible use of time when teaching, adapting the mix of teaching and independent learning activities to optimize use of the time available.
Develop a repertoire of teaching and supervision methods that enhance a learner's knowledge base, clinical skills, and attitudes/behaviors, including:
Bedside teaching
Teaching during work rounds
Lectures or case‐based discussions using multimedia presentation methods
Teaching a specific skill or procedure
Affirm competency when learner masters a skill
Role modeling for learners, with articulation of thought process
Written instruction
Provide frequent, effective feedback based upon direct observation of trainee's clinical, communication, and technical skills and professionalism.
Teach effectively in large group settings, such as hospital or community setting conferences.
Teach effectively in small groups using a case‐based format.
Use different types of questioning (broadening, justifying, hypothetical, and alternative)
Address learning needs of trainees of different levels of experience
Teach patients and the family/caregiver about the diagnosis, planned investigation, management plan and prognosis in an interactive, family centered manner.
Attitudes
Pediatric hospitalists should be able to:
Promote a climate of continuous learning by acknowledging one's own knowledge gaps and prompting learners to teach each other.
Model effective and empathetic communication with patients and the family/caregiver when educating.
Encourage trainees to be self‐directed and to learn independently.
Model professional behavior by being prompt, prepared, available, and approachable in educational efforts.
Build and maintain teamwork by providing reinforcing as well as corrective feedback.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Partner with training programs to create, maintain, and implement inpatient hospital medicine education.
Work with hospital administrators to maintain adequate trainee supervision to ensure patient safety, while encouraging development of autonomous practice.
Through educational efforts, promote quality improvement, patient safety, cost effective care, evidence based medicine and effective communication around inpatient pediatric care.
Integrate and explain the rationale behind established clinical pathways and prompt trainees to use them consistently.
Address the balance of teaching and patient care responsibilities with hospital administration and training program directors to maximize the effectiveness of both.
Collaborate with hospital administration to ensure adequate teaching facilities.
Copyright © 2010 Society of Hospital Medicine