Introduction

Failure to thrive (FTT) is a descriptive term that refers to a child with relative undernutrition and subsequent inadequate growth over time, when compared to other children of similar age, gender, and ethnicity. Several definitions have been proposed based on abnormal anthropometric criteria, but none is uniformly accepted. The etiology of FTT is often multifactorial and results from a complex interplay between psychosocial, behavioral, and physiological factors. Ultimately, this interaction leads to one of three outcomes inadequate caloric intake (in the setting of normal or excessive metabolic demands), inadequate absorption of calories, or impaired utilization of absorbed calories. FTT is often successfully managed in the outpatient setting. However, hospitalization may be necessary for very complex situations, when a child's safety is in question, or when outpatient management has not been successful. It is estimated that FTT accounts for 1 to 5% of all pediatric hospitalizations. Pediatric hospitalists should use evidence‐based approaches to guide evaluation and management, provide leadership for multidisciplinary teams, and coordinate care to optimize outcomes.

Knowledge

Pediatric hospitalists should be able to:

• Describe the differential diagnosis of FTT for children of varying chronological and developmental ages recognizing that most children with FTT do not have an underlying medical disorder.

• Explain why infants and toddlers are at greater risk for FTT than older children.

• Describe the association between FTT and child abuse and neglect.

• Describe normal growth patterns for children and the sequential effect of undernutrition on weight velocity, height velocity, and head growth.

• Describe the key historical or physical examination findings that may indicate a psychosocial, behavioral, or physiological factor contributing to poor growth.

• Provide indications for admission to the hospital and state criteria for determining the appropriate level of care (ward vs. intensive care unit).

• Describe the goals of hospitalization including stabilization, diagnosis, treatment, observation, and education.

• Discuss the importance of observation of feeding behaviors and recording of nutritional intake over time in the evaluation of FTT.

• State the indications for laboratory, radiographic, or other testing in the evaluation of FTT.

• Discuss the indications for consultation with a pediatric speech or occupational therapist, nutritionist, gastroenterologist or other subspecialist.

• Discuss the need for catch‐up calories in FTT, as well as the methods by which to achieve adequate caloric supplementation.

• Define the refeeding syndrome, and describe methods to prevent it or lead to its early detection.

• Discuss potential sequelae of FTT (such as behavioral or developmental abnormalities, increased susceptibility to infections, and others) and list the risk factors for worse outcomes.

• Summarize the literature on the impact of hospitalization on the evaluation, management, and outcomes for FTT.

Skills

Pediatric hospitalists should be able to:

• Stabilize patients presenting with metabolic abnormalities, cardiopulmonary compromise, or other urgent problems as a result of dehydration, malnutrition, or an abnormal pathophysiological state.

• Obtain a thorough patient history, including a detailed social, family, dietary and feeding history, attending to markers of abnormal behavioral or psychosocial factors.

• Perform a directed physical examination, including careful measurement of anthropometric data, attending to findings that may indicate an underlying medical condition or child abuse and neglect.

• Correctly utilize standardized growth charts to identify isolated growth abnormalities and to assess the growth pattern over time.

• Directly observe and correctly interpret a feeding session, with attention paid to feeding behavior and the child‐caregiver interactions.

• Critically assess the level of evidence and risk/benefit ratio for an expanded diagnostic evaluation.

• Interpret basic tests and identify abnormal findings that require further testing or consultation.

• Correctly calculate caloric needs and adjust feeding regimens to maximize weight gain while avoiding gastrointestinal compromise.

• Correctly identify the need for and efficiently access appropriate consultants and support services needed to provide comprehensive care.

• Coordinate care with subspecialists, the primary care provider and other services and arrange for an appropriate transition plan with detailed follow‐up plans for after hospital discharge.

Attitudes

Pediatric hospitalists should be able to:

• Consider the concerns of the family/caregiver when obtaining a history, developing a diagnostic approach, and offering anticipatory guidance and management options.

• Provide education to the family/caregiver on FTT, with specific focus on patient‐specific underlying diagnoses.

• Communicate effectively with the family/caregiver and healthcare providers regarding findings and care plans.

• Maintain the continuum of care by effectively coordinating the discharge with the primary care provider.

Systems Organization and Improvement

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

• Coordinate the care of professional staff (including social work, nursing, speech or occupational therapists) and consultants to improve the quality and efficiency of care.

• Work with healthcare providers and community leaders to develop a system for effective and safe transitions of care from the inpatient to outpatient healthcare providers, preserving the multidisciplinary nature of the care team when appropriate.

• Lead, coordinate or participate in efforts to develop evidence‐based guidelines for the evaluation and management of FTT in the hospital.

Introduction

Failure to thrive (FTT) is a descriptive term that refers to a child with relative undernutrition and subsequent inadequate growth over time, when compared to other children of similar age, gender, and ethnicity. Several definitions have been proposed based on abnormal anthropometric criteria, but none is uniformly accepted. The etiology of FTT is often multifactorial and results from a complex interplay between psychosocial, behavioral, and physiological factors. Ultimately, this interaction leads to one of three outcomes inadequate caloric intake (in the setting of normal or excessive metabolic demands), inadequate absorption of calories, or impaired utilization of absorbed calories. FTT is often successfully managed in the outpatient setting. However, hospitalization may be necessary for very complex situations, when a child's safety is in question, or when outpatient management has not been successful. It is estimated that FTT accounts for 1 to 5% of all pediatric hospitalizations. Pediatric hospitalists should use evidence‐based approaches to guide evaluation and management, provide leadership for multidisciplinary teams, and coordinate care to optimize outcomes.

Knowledge

Pediatric hospitalists should be able to:

• Describe the differential diagnosis of FTT for children of varying chronological and developmental ages recognizing that most children with FTT do not have an underlying medical disorder.

• Explain why infants and toddlers are at greater risk for FTT than older children.

• Describe the association between FTT and child abuse and neglect.

• Describe normal growth patterns for children and the sequential effect of undernutrition on weight velocity, height velocity, and head growth.

• Describe the key historical or physical examination findings that may indicate a psychosocial, behavioral, or physiological factor contributing to poor growth.

• Provide indications for admission to the hospital and state criteria for determining the appropriate level of care (ward vs. intensive care unit).

• Describe the goals of hospitalization including stabilization, diagnosis, treatment, observation, and education.

• Discuss the importance of observation of feeding behaviors and recording of nutritional intake over time in the evaluation of FTT.

• State the indications for laboratory, radiographic, or other testing in the evaluation of FTT.

• Discuss the indications for consultation with a pediatric speech or occupational therapist, nutritionist, gastroenterologist or other subspecialist.

• Discuss the need for catch‐up calories in FTT, as well as the methods by which to achieve adequate caloric supplementation.

• Define the refeeding syndrome, and describe methods to prevent it or lead to its early detection.

• Discuss potential sequelae of FTT (such as behavioral or developmental abnormalities, increased susceptibility to infections, and others) and list the risk factors for worse outcomes.

• Summarize the literature on the impact of hospitalization on the evaluation, management, and outcomes for FTT.

Skills

Pediatric hospitalists should be able to:

• Stabilize patients presenting with metabolic abnormalities, cardiopulmonary compromise, or other urgent problems as a result of dehydration, malnutrition, or an abnormal pathophysiological state.

• Obtain a thorough patient history, including a detailed social, family, dietary and feeding history, attending to markers of abnormal behavioral or psychosocial factors.

• Perform a directed physical examination, including careful measurement of anthropometric data, attending to findings that may indicate an underlying medical condition or child abuse and neglect.

• Correctly utilize standardized growth charts to identify isolated growth abnormalities and to assess the growth pattern over time.

• Directly observe and correctly interpret a feeding session, with attention paid to feeding behavior and the child‐caregiver interactions.

• Critically assess the level of evidence and risk/benefit ratio for an expanded diagnostic evaluation.

• Interpret basic tests and identify abnormal findings that require further testing or consultation.

• Correctly calculate caloric needs and adjust feeding regimens to maximize weight gain while avoiding gastrointestinal compromise.

• Correctly identify the need for and efficiently access appropriate consultants and support services needed to provide comprehensive care.

• Coordinate care with subspecialists, the primary care provider and other services and arrange for an appropriate transition plan with detailed follow‐up plans for after hospital discharge.

Attitudes

Pediatric hospitalists should be able to:

• Consider the concerns of the family/caregiver when obtaining a history, developing a diagnostic approach, and offering anticipatory guidance and management options.

• Provide education to the family/caregiver on FTT, with specific focus on patient‐specific underlying diagnoses.

• Communicate effectively with the family/caregiver and healthcare providers regarding findings and care plans.

• Maintain the continuum of care by effectively coordinating the discharge with the primary care provider.

Systems Organization and Improvement

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

• Coordinate the care of professional staff (including social work, nursing, speech or occupational therapists) and consultants to improve the quality and efficiency of care.

• Work with healthcare providers and community leaders to develop a system for effective and safe transitions of care from the inpatient to outpatient healthcare providers, preserving the multidisciplinary nature of the care team when appropriate.

• Lead, coordinate or participate in efforts to develop evidence‐based guidelines for the evaluation and management of FTT in the hospital.

Introduction

Failure to thrive (FTT) is a descriptive term that refers to a child with relative undernutrition and subsequent inadequate growth over time, when compared to other children of similar age, gender, and ethnicity. Several definitions have been proposed based on abnormal anthropometric criteria, but none is uniformly accepted. The etiology of FTT is often multifactorial and results from a complex interplay between psychosocial, behavioral, and physiological factors. Ultimately, this interaction leads to one of three outcomes inadequate caloric intake (in the setting of normal or excessive metabolic demands), inadequate absorption of calories, or impaired utilization of absorbed calories. FTT is often successfully managed in the outpatient setting. However, hospitalization may be necessary for very complex situations, when a child's safety is in question, or when outpatient management has not been successful. It is estimated that FTT accounts for 1 to 5% of all pediatric hospitalizations. Pediatric hospitalists should use evidence‐based approaches to guide evaluation and management, provide leadership for multidisciplinary teams, and coordinate care to optimize outcomes.

Knowledge

Pediatric hospitalists should be able to:

• Describe the differential diagnosis of FTT for children of varying chronological and developmental ages recognizing that most children with FTT do not have an underlying medical disorder.

• Explain why infants and toddlers are at greater risk for FTT than older children.

• Describe the association between FTT and child abuse and neglect.

• Describe normal growth patterns for children and the sequential effect of undernutrition on weight velocity, height velocity, and head growth.

• Describe the key historical or physical examination findings that may indicate a psychosocial, behavioral, or physiological factor contributing to poor growth.

• Provide indications for admission to the hospital and state criteria for determining the appropriate level of care (ward vs. intensive care unit).

• Describe the goals of hospitalization including stabilization, diagnosis, treatment, observation, and education.

• Discuss the importance of observation of feeding behaviors and recording of nutritional intake over time in the evaluation of FTT.

• State the indications for laboratory, radiographic, or other testing in the evaluation of FTT.

• Discuss the indications for consultation with a pediatric speech or occupational therapist, nutritionist, gastroenterologist or other subspecialist.

• Discuss the need for catch‐up calories in FTT, as well as the methods by which to achieve adequate caloric supplementation.

• Define the refeeding syndrome, and describe methods to prevent it or lead to its early detection.

• Discuss potential sequelae of FTT (such as behavioral or developmental abnormalities, increased susceptibility to infections, and others) and list the risk factors for worse outcomes.

• Summarize the literature on the impact of hospitalization on the evaluation, management, and outcomes for FTT.

Skills

Pediatric hospitalists should be able to:

• Stabilize patients presenting with metabolic abnormalities, cardiopulmonary compromise, or other urgent problems as a result of dehydration, malnutrition, or an abnormal pathophysiological state.

• Obtain a thorough patient history, including a detailed social, family, dietary and feeding history, attending to markers of abnormal behavioral or psychosocial factors.

• Perform a directed physical examination, including careful measurement of anthropometric data, attending to findings that may indicate an underlying medical condition or child abuse and neglect.

• Correctly utilize standardized growth charts to identify isolated growth abnormalities and to assess the growth pattern over time.

• Directly observe and correctly interpret a feeding session, with attention paid to feeding behavior and the child‐caregiver interactions.

• Critically assess the level of evidence and risk/benefit ratio for an expanded diagnostic evaluation.

• Interpret basic tests and identify abnormal findings that require further testing or consultation.

• Correctly calculate caloric needs and adjust feeding regimens to maximize weight gain while avoiding gastrointestinal compromise.

• Correctly identify the need for and efficiently access appropriate consultants and support services needed to provide comprehensive care.

• Coordinate care with subspecialists, the primary care provider and other services and arrange for an appropriate transition plan with detailed follow‐up plans for after hospital discharge.

Attitudes

Pediatric hospitalists should be able to:

• Consider the concerns of the family/caregiver when obtaining a history, developing a diagnostic approach, and offering anticipatory guidance and management options.

• Provide education to the family/caregiver on FTT, with specific focus on patient‐specific underlying diagnoses.

• Communicate effectively with the family/caregiver and healthcare providers regarding findings and care plans.

• Maintain the continuum of care by effectively coordinating the discharge with the primary care provider.

Systems Organization and Improvement

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

• Coordinate the care of professional staff (including social work, nursing, speech or occupational therapists) and consultants to improve the quality and efficiency of care.

• Work with healthcare providers and community leaders to develop a system for effective and safe transitions of care from the inpatient to outpatient healthcare providers, preserving the multidisciplinary nature of the care team when appropriate.

• Lead, coordinate or participate in efforts to develop evidence‐based guidelines for the evaluation and management of FTT in the hospital.

Introduction

Cardiorespiratory monitoring is used commonly during hospitalization, and electrocardiograms (ECGs) are often obtained to screen for or diagnose cardiac pathology. Cardiac arrhythmias in the hospital setting can be of clinical significance and may be life‐threatening. Early recognition of a clinically significant arrhythmia will result in rapid implementation of appropriate and life‐saving interventions. Pediatric hospitalists are often in the best position to recognize, diagnose, and provide the initial treatment for cardiac arrhythmias and other cardiac problems. Pediatric hospitalists should be skilled at obtaining and interpreting ECGs.

Knowledge

Pediatric hospitalists should be able to:

• Describe the normal electrical cardiac cycle and the corresponding wave forms on an ECG tracing.

• Review the steps in performing an ECG, attending to lead placement and other technical aspects of the procedure.

• Summarize a general approach to the interpretation of pediatric ECGs, attending to evaluation of heart rate, rhythm, QRS axis, wave form durations and intervals, and chamber hypertrophy.

• Compare and contrast the features of the newborn ECG to those of older children and adults.

• Describe the common ECG changes associated with specific electrolyte disturbances.

• List the medications associated with potentially serious arrhythmias (e.g. cisapride and prolonged QT syndrome).

• Describe the appropriate treatment for specific cardiac arrhythmias (e.g. medications, electrical cardioversion, or defibrillation).

• List the ECG findings that should prompt consultation with a cardiologist, including life‐threatening or unstable cardiac arrhythmia.

Skills

Pediatric hospitalists should be able to:

• Obtain an ECG using the standard number and placement of leads, recording speed, and sensitivity.

• Differentiate between a normal sinus rhythm and other rhythms by evaluating the presence and relationship of the P wave to the QRS complex.

• Determine the heart rate, considering both the atrial and ventricular rates if different.

• Determine the PR and QT intervals, P and QRS durations, and QRS axis.

• Calculate the corrected QT interval (QTc) for the evaluation of prolonged QT syndrome.

• Use the calculated intervals, durations, and amplitudes to evaluate for chamber hypertrophy and to screen for ischemia.

• Recognize patterns that are pathognomonic for certain diagnoses (e.g., delta waves in Wolff‐Parkinson‐White syndrome).

• Correctly identify abnormal cardiac rhythms and respond with appropriate actions and interventions, including medications, electrical cardioversion, and defibrillation.

• Order appropriate monitoring and correctly interpret monitor data.

• Consult a pediatric cardiologist when indicated.

Attitudes

Pediatric hospitalists should be able to:

• Assume responsibility for the need to obtain an ECG and provide an accurate interpretation.

• Communicate effectively with patients, the family/caregivers and other healthcare providers regarding the need to obtain an ECG, findings, and care plan.

• Collaborate with the primary care provider and subspecialists to ensure coordinated longitudinal care for children with cardiac pathology.

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 and evidence‐based policies regarding the indications for obtaining an ECG.

• Work with pediatric cardiologists, hospital staff, and others to ensure timely, reliable and accurate pediatric ECG interpretation.

• Lead, coordinate, or participate in efforts directed at educating healthcare providers about risk factors for cardiac arrhythmia, early identification of abnormal rhythms, and implementation of appropriate resuscitative efforts.

Introduction

Cardiorespiratory monitoring is used commonly during hospitalization, and electrocardiograms (ECGs) are often obtained to screen for or diagnose cardiac pathology. Cardiac arrhythmias in the hospital setting can be of clinical significance and may be life‐threatening. Early recognition of a clinically significant arrhythmia will result in rapid implementation of appropriate and life‐saving interventions. Pediatric hospitalists are often in the best position to recognize, diagnose, and provide the initial treatment for cardiac arrhythmias and other cardiac problems. Pediatric hospitalists should be skilled at obtaining and interpreting ECGs.

Knowledge

Pediatric hospitalists should be able to:

• Describe the normal electrical cardiac cycle and the corresponding wave forms on an ECG tracing.

• Review the steps in performing an ECG, attending to lead placement and other technical aspects of the procedure.

• Summarize a general approach to the interpretation of pediatric ECGs, attending to evaluation of heart rate, rhythm, QRS axis, wave form durations and intervals, and chamber hypertrophy.

• Compare and contrast the features of the newborn ECG to those of older children and adults.

• Describe the common ECG changes associated with specific electrolyte disturbances.

• List the medications associated with potentially serious arrhythmias (e.g. cisapride and prolonged QT syndrome).

• Describe the appropriate treatment for specific cardiac arrhythmias (e.g. medications, electrical cardioversion, or defibrillation).

• List the ECG findings that should prompt consultation with a cardiologist, including life‐threatening or unstable cardiac arrhythmia.

Skills

Pediatric hospitalists should be able to:

• Obtain an ECG using the standard number and placement of leads, recording speed, and sensitivity.

• Differentiate between a normal sinus rhythm and other rhythms by evaluating the presence and relationship of the P wave to the QRS complex.

• Determine the heart rate, considering both the atrial and ventricular rates if different.

• Determine the PR and QT intervals, P and QRS durations, and QRS axis.

• Calculate the corrected QT interval (QTc) for the evaluation of prolonged QT syndrome.

• Use the calculated intervals, durations, and amplitudes to evaluate for chamber hypertrophy and to screen for ischemia.

• Recognize patterns that are pathognomonic for certain diagnoses (e.g., delta waves in Wolff‐Parkinson‐White syndrome).

• Correctly identify abnormal cardiac rhythms and respond with appropriate actions and interventions, including medications, electrical cardioversion, and defibrillation.

• Order appropriate monitoring and correctly interpret monitor data.

• Consult a pediatric cardiologist when indicated.

Attitudes

Pediatric hospitalists should be able to:

• Assume responsibility for the need to obtain an ECG and provide an accurate interpretation.

• Communicate effectively with patients, the family/caregivers and other healthcare providers regarding the need to obtain an ECG, findings, and care plan.

• Collaborate with the primary care provider and subspecialists to ensure coordinated longitudinal care for children with cardiac pathology.

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 and evidence‐based policies regarding the indications for obtaining an ECG.

• Work with pediatric cardiologists, hospital staff, and others to ensure timely, reliable and accurate pediatric ECG interpretation.

• Lead, coordinate, or participate in efforts directed at educating healthcare providers about risk factors for cardiac arrhythmia, early identification of abnormal rhythms, and implementation of appropriate resuscitative efforts.

Introduction

Cardiorespiratory monitoring is used commonly during hospitalization, and electrocardiograms (ECGs) are often obtained to screen for or diagnose cardiac pathology. Cardiac arrhythmias in the hospital setting can be of clinical significance and may be life‐threatening. Early recognition of a clinically significant arrhythmia will result in rapid implementation of appropriate and life‐saving interventions. Pediatric hospitalists are often in the best position to recognize, diagnose, and provide the initial treatment for cardiac arrhythmias and other cardiac problems. Pediatric hospitalists should be skilled at obtaining and interpreting ECGs.

Knowledge

Pediatric hospitalists should be able to:

• Describe the normal electrical cardiac cycle and the corresponding wave forms on an ECG tracing.

• Review the steps in performing an ECG, attending to lead placement and other technical aspects of the procedure.

• Summarize a general approach to the interpretation of pediatric ECGs, attending to evaluation of heart rate, rhythm, QRS axis, wave form durations and intervals, and chamber hypertrophy.

• Compare and contrast the features of the newborn ECG to those of older children and adults.

• Describe the common ECG changes associated with specific electrolyte disturbances.

• List the medications associated with potentially serious arrhythmias (e.g. cisapride and prolonged QT syndrome).

• Describe the appropriate treatment for specific cardiac arrhythmias (e.g. medications, electrical cardioversion, or defibrillation).

• List the ECG findings that should prompt consultation with a cardiologist, including life‐threatening or unstable cardiac arrhythmia.

Skills

Pediatric hospitalists should be able to:

• Obtain an ECG using the standard number and placement of leads, recording speed, and sensitivity.

• Differentiate between a normal sinus rhythm and other rhythms by evaluating the presence and relationship of the P wave to the QRS complex.

• Determine the heart rate, considering both the atrial and ventricular rates if different.

• Determine the PR and QT intervals, P and QRS durations, and QRS axis.

• Calculate the corrected QT interval (QTc) for the evaluation of prolonged QT syndrome.

• Use the calculated intervals, durations, and amplitudes to evaluate for chamber hypertrophy and to screen for ischemia.

• Recognize patterns that are pathognomonic for certain diagnoses (e.g., delta waves in Wolff‐Parkinson‐White syndrome).

• Correctly identify abnormal cardiac rhythms and respond with appropriate actions and interventions, including medications, electrical cardioversion, and defibrillation.

• Order appropriate monitoring and correctly interpret monitor data.

• Consult a pediatric cardiologist when indicated.

Attitudes

Pediatric hospitalists should be able to:

• Assume responsibility for the need to obtain an ECG and provide an accurate interpretation.

• Communicate effectively with patients, the family/caregivers and other healthcare providers regarding the need to obtain an ECG, findings, and care plan.

• Collaborate with the primary care provider and subspecialists to ensure coordinated longitudinal care for children with cardiac pathology.

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 and evidence‐based policies regarding the indications for obtaining an ECG.

• Work with pediatric cardiologists, hospital staff, and others to ensure timely, reliable and accurate pediatric ECG interpretation.

• Lead, coordinate, or participate in efforts directed at educating healthcare providers about risk factors for cardiac arrhythmia, early identification of abnormal rhythms, and implementation of appropriate resuscitative efforts.

Introduction

The Society of Hospital Medicine (SHM) defines hospitalists as physicians whose primary professional focus is the comprehensive general medical care of hospitalized patients. Their activities include patient care, teaching, research, and leadership related to Hospital Medicine.1 It is estimated that there are up to 2500 pediatric hospitalists in the United States, with continued growth due to the converging needs for a dedicated focus on patient safety, quality improvement, hospital throughput, and inpatient teaching.2‐9 (Pediatric Hospital Medicine (PHM), as defined today, has been practiced in the United States for at least 30 years10 and continues to evolve as an area of specialization, with the refinement of a distinct knowledgebase and skill set focused on the provision of high quality general pediatric care in the inpatient setting. PHM is the latest site‐specific specialty to emerge from the field of general pediatrics it's development analogous to the evolution of critical care or emergency medicine during previous decades.11 Adult hospital medicine has defined itself within the field of general internal medicine12 and has recently received approval to provide a recognized focus of practice exam in 2010 for those re‐certifying with the American Board of Internal Medicine,13 PHM is creating an identity as a subspecialty practice with distinct focus on inpatient care for children within the larger context of general pediatric care.8, 14

The Pediatric Hospital Medicine Core Competencies were created to help define the roles and expectations for pediatric hospitalists, regardless of practice setting. The intent is to provide a unified approach toward identifying the specific body of knowledge and measurable skills needed to assure delivery of the highest quality of care for all hospitalized pediatric patients. Most children requiring hospitalization in the United States are hospitalized in community settings where subspecialty support is more limited and many pediatric services may be unavailable. Children with complex, chronic medical problems, however, are more likely to be hospitalized at a tertiary care or academic institutions. In order to unify pediatric hospitalists who work in different practice environments, the PHM Core Competencies were constructed to represent the knowledge, skills, attitudes, and systems improvements that all pediatric hospitalists can be expected to acquire and maintain.

Furthermore, the content of the PHM Core Competencies reflect the fact that children are a vulnerable population. Their care requires attention to many elements which distinguishes it from that given to the majority of the adult population: dependency, differences in developmental physiology and behavior, occurrence of congenital genetic disorders and age‐based clinical conditions, impact of chronic disease states on whole child development, and weight‐based medication dosing often with limited guidance from pediatric studies, to name a few. Awareness of these needs must be heightened when a child enters the hospital where diagnoses, procedures, and treatments often include use of high‐risk modalities and require coordination of care across multiple providers.

Pediatric hospitalists commonly work to improve the systems of care in which they operate and therefore both clinical and non‐clinical topics are included. The 54 chapters address the fundamental and most common components of inpatient care but are not an extensive review of all aspects of inpatient medicine encountered by those caring for hospitalized children. Finally, the PHM Core Competencies are not intended for use in assessing proficiency immediately post‐residency, but do provide a framework for the education and evaluation of both physicians‐in‐training and practicing hospitalists. Meeting these competencies is anticipated to take from one to three years of active practice in pediatric hospital medicine, and may be reached through a combination of practice experience, course work, self‐directed work, and/or formalized training.

Methods

Areas of Focused Practice

The PHM Core Competencies were conceptualized similarly to the SHM adult core competencies. Initial sections were divided into clinical conditions, procedures, and systems. However as content developed and reviewer comments were addressed, the four final sections were modified to those noted in Table 2. For the Common Clinical Diagnoses and Conditions, the goal was to select conditions most commonly encountered by pediatric hospitalists. Non‐surgical diagnosis‐related group (DRG) conditions were selected from the following sources: The Joint Commission's (TJC) Oryx Performance Measures Report15‐16 (asthma, abdominal pain, acute gastroenteritis, simple pneumonia); Child Health Corporation of America's Pediatric Health Information System Dataset (CHCA PHIS, Shawnee Mission, KS), and relevant publications on common pediatric hospitalizations.17 These data were compared to billing data from randomly‐selected practicing hospitalists representing free‐standing children's and community hospitals, teaching and non‐teaching settings, and urban and rural locations. The 22 clinical conditions chosen by the CCTF were those most relevant to the practice of pediatric hospital medicine.

The Specialized Clinical Servicessection addresses important components of care that are not DRG‐based and reflect the unique needs of hospitalized children, as assessed by the CCTF, editors, and contributors. Core Skillswere chosen based on the HCUP Factbook 2 Procedures,18 billing data from randomly‐selected practicing hospitalists representing the same settings listed above, and critical input from reviewers. Depending on the individual setting, pediatric hospitalists may require skills in areas not found in these 11 chapters, such as chest tube placement or ventilator management. The list is therefore not exhaustive, but rather representative of skills most pediatric hospitalists should maintain.

The Healthcare Systems: Supporting and Advancing Child Healthchapters are likely the most dissimilar to any core content taught in traditional residency programs. While residency graduates are versed in some components listed in these chapters, comprehensive education in most of these competencies is currently lacking. Improvement of healthcare systems is an essential element of pediatric hospital medicine, and unifies all pediatric hospitalists regardless of practice environment or patient population. Therefore, this section includes chapters that not only focus on systems of care, but also on advancing child health through advocacy, research, education, evidence‐based medicine, and ethical practice. These chapters were drawn from a combination of several sources: expectations of external agencies (TJC, Center for Medicaid and Medicare) related to the specific nonclinical work in which pediatric hospitalists are integrally involved; expectations for advocacy as best defined by the AAP and the National Association of Children's Hospitals and Related Institutions (NACHRI); the six core competency domains mandated by the Accrediting Council on Graduate Medical Education (ACGME), the American Board of Pediatrics (ABP), and hospital medical staff offices as part of Focused Professional Practice Evaluation (FPPE) and Ongoing Professional Practice Evaluation (OPPE)16; and assessment of responsibilities and leadership roles fulfilled by pediatric hospitalists in all venues. In keeping with the intent of the competencies to be timeless, the competency elements call out the need to attend to the changing goals of these groups as well as those of the Institute of Healthcare Improvement (IHI), the Alliance for Pediatric Quality (which consists of ABP, AAP, TJC, CHCA, NACHRI), and local hospital systems leaders.

Contributors and Review

The CCTF selected section (associate) editors from SHM based on established expertise in each area, with input from the SHM Pediatric and Education Committees and the SHM Board. As a collaborative effort, authors for various chapters were solicited in consultation with experts from the AAP, APA, and SHM, and included non‐hospitalists with reputations as experts in various fields. Numerous SHM Pediatric Committee and CCTF conference calls were held to review hospital and academic appointments, presentations given, and affiliations relevant to the practice of pediatric hospital medicine. This vetting process resulted in a robust author list representing diverse geographic and practice settings. Contributors were provided with structure (Knowledge, Skills, Attitudes, and Systems subsections) and content (timeless, competency based) guidelines.

The review process was rigorous, and included both internal and external reviewers. The APA review in 2007 included the PHM Special Interest Group as well as the PHM Fellowship Directors (Table 1). After return to SHM and further editing, the internal review commenced which focused on content and scope. The editors addressed the resulting suggestions and worked to standardize formatting and use of Bloom's taxonomy.19 A list of common terms and phrases were created to add consistency between chapters. External reviewers were first mailed a letter requesting interest, which was followed up by emails, letters, and phone calls to encourage feedback. External review included 29 solicited agencies and societies (Table 3), with overall response rate of 66% (41% for Groups I and II). Individual contributors then reviewed comments specific to their chapters, with associate editor overview of their respective sections. The editors reviewed each chapter individually multiple times throughout the 2007‐2009 years, contacting individual contributors and reviewers by email and phone. Editors concluded a final comprehensive review of all chapters in late 2009.

Chapter Content

Each of the 54 chapters within the four sections of these competencies is presented in the educational theory of learning domains: Knowledge, Skills, Attitudes, with a final Systems domain added to reflect the emphasis of hospitalist practice on improving healthcare systems. Each chapter is designed to stand alone, which may assist with development of curriculum at individual practice locations. Certain key phrases are apparent throughout, such as lead, coordinate, or participate in and work with hospital and community leaders to which were designed to note the varied roles in different practice settings. Some chapters specifically comment on the application of competency bullets given the unique and differing roles and expectations of pediatric hospitalists, such as research and education. Chapters state specific proficiencies expected wherever possible, with phrases and wording selected to help guide learning activities to achieve the competency.

Application and Future Directions

Although pediatric hospitalists care for children in many settings, these core competencies address the common expectations for any venue. Pediatric hospital medicine requires skills in acute care clinical medicine that attend to the changing needs of hospitalized children. The core of pediatric hospital medicine is dedicated to the care of children in the geographic hospital environment between emergency medicine and tertiary pediatric and neonatal intensive care units. Pediatric hospitalists provide care in related clinical service programs that are linked to hospital systems. In performing these activities, pediatric hospitalists consistently partner with ambulatory providers and subspecialists to render coordinated care across the continuum for a given child. Pediatric hospital medicine is an interdisciplinary practice, with focus on processes of care and clinical quality outcomes based in evidence. Engagement in local, state, and national initiatives to improve child health outcomes is a cornerstone of pediatric hospitalists' practice. These competencies provide the framework for creation of curricula that can reflect local issues and react to changing evidence.

As providers of systems‐based care, pediatric hospitalists are called upon more and more to render care and provide leadership in clinical arenas that are integral to healthcare organizations, such as home health care, sub‐acute care facilities, and hospice and palliative care programs. The practice of pediatric hospital medicine has evolved to its current state through efforts of many represented in the competencies as contributors, associate editors, editors, and reviewers. Pediatric hospitalists are committed to leading change in healthcare for hospitalized children, and are positioned well to address the interests and needs of community and urban, teaching and non‐teaching facilities, and the children and families they serve. These competencies reflect the areas of focused practice which, similar to pediatric emergency medicine, will no doubt be refined but not fundamentally changed in future years. The intent, we hope, is clear: to provide excellence in clinical care, accountability for practice, and lead improvements in healthcare for hospitalized children.

Introduction

The Society of Hospital Medicine (SHM) defines hospitalists as physicians whose primary professional focus is the comprehensive general medical care of hospitalized patients. Their activities include patient care, teaching, research, and leadership related to Hospital Medicine.1 It is estimated that there are up to 2500 pediatric hospitalists in the United States, with continued growth due to the converging needs for a dedicated focus on patient safety, quality improvement, hospital throughput, and inpatient teaching.2‐9 (Pediatric Hospital Medicine (PHM), as defined today, has been practiced in the United States for at least 30 years10 and continues to evolve as an area of specialization, with the refinement of a distinct knowledgebase and skill set focused on the provision of high quality general pediatric care in the inpatient setting. PHM is the latest site‐specific specialty to emerge from the field of general pediatrics it's development analogous to the evolution of critical care or emergency medicine during previous decades.11 Adult hospital medicine has defined itself within the field of general internal medicine12 and has recently received approval to provide a recognized focus of practice exam in 2010 for those re‐certifying with the American Board of Internal Medicine,13 PHM is creating an identity as a subspecialty practice with distinct focus on inpatient care for children within the larger context of general pediatric care.8, 14

The Pediatric Hospital Medicine Core Competencies were created to help define the roles and expectations for pediatric hospitalists, regardless of practice setting. The intent is to provide a unified approach toward identifying the specific body of knowledge and measurable skills needed to assure delivery of the highest quality of care for all hospitalized pediatric patients. Most children requiring hospitalization in the United States are hospitalized in community settings where subspecialty support is more limited and many pediatric services may be unavailable. Children with complex, chronic medical problems, however, are more likely to be hospitalized at a tertiary care or academic institutions. In order to unify pediatric hospitalists who work in different practice environments, the PHM Core Competencies were constructed to represent the knowledge, skills, attitudes, and systems improvements that all pediatric hospitalists can be expected to acquire and maintain.

Furthermore, the content of the PHM Core Competencies reflect the fact that children are a vulnerable population. Their care requires attention to many elements which distinguishes it from that given to the majority of the adult population: dependency, differences in developmental physiology and behavior, occurrence of congenital genetic disorders and age‐based clinical conditions, impact of chronic disease states on whole child development, and weight‐based medication dosing often with limited guidance from pediatric studies, to name a few. Awareness of these needs must be heightened when a child enters the hospital where diagnoses, procedures, and treatments often include use of high‐risk modalities and require coordination of care across multiple providers.

Pediatric hospitalists commonly work to improve the systems of care in which they operate and therefore both clinical and non‐clinical topics are included. The 54 chapters address the fundamental and most common components of inpatient care but are not an extensive review of all aspects of inpatient medicine encountered by those caring for hospitalized children. Finally, the PHM Core Competencies are not intended for use in assessing proficiency immediately post‐residency, but do provide a framework for the education and evaluation of both physicians‐in‐training and practicing hospitalists. Meeting these competencies is anticipated to take from one to three years of active practice in pediatric hospital medicine, and may be reached through a combination of practice experience, course work, self‐directed work, and/or formalized training.

Methods

Areas of Focused Practice

The PHM Core Competencies were conceptualized similarly to the SHM adult core competencies. Initial sections were divided into clinical conditions, procedures, and systems. However as content developed and reviewer comments were addressed, the four final sections were modified to those noted in Table 2. For the Common Clinical Diagnoses and Conditions, the goal was to select conditions most commonly encountered by pediatric hospitalists. Non‐surgical diagnosis‐related group (DRG) conditions were selected from the following sources: The Joint Commission's (TJC) Oryx Performance Measures Report15‐16 (asthma, abdominal pain, acute gastroenteritis, simple pneumonia); Child Health Corporation of America's Pediatric Health Information System Dataset (CHCA PHIS, Shawnee Mission, KS), and relevant publications on common pediatric hospitalizations.17 These data were compared to billing data from randomly‐selected practicing hospitalists representing free‐standing children's and community hospitals, teaching and non‐teaching settings, and urban and rural locations. The 22 clinical conditions chosen by the CCTF were those most relevant to the practice of pediatric hospital medicine.

The Specialized Clinical Servicessection addresses important components of care that are not DRG‐based and reflect the unique needs of hospitalized children, as assessed by the CCTF, editors, and contributors. Core Skillswere chosen based on the HCUP Factbook 2 Procedures,18 billing data from randomly‐selected practicing hospitalists representing the same settings listed above, and critical input from reviewers. Depending on the individual setting, pediatric hospitalists may require skills in areas not found in these 11 chapters, such as chest tube placement or ventilator management. The list is therefore not exhaustive, but rather representative of skills most pediatric hospitalists should maintain.

The Healthcare Systems: Supporting and Advancing Child Healthchapters are likely the most dissimilar to any core content taught in traditional residency programs. While residency graduates are versed in some components listed in these chapters, comprehensive education in most of these competencies is currently lacking. Improvement of healthcare systems is an essential element of pediatric hospital medicine, and unifies all pediatric hospitalists regardless of practice environment or patient population. Therefore, this section includes chapters that not only focus on systems of care, but also on advancing child health through advocacy, research, education, evidence‐based medicine, and ethical practice. These chapters were drawn from a combination of several sources: expectations of external agencies (TJC, Center for Medicaid and Medicare) related to the specific nonclinical work in which pediatric hospitalists are integrally involved; expectations for advocacy as best defined by the AAP and the National Association of Children's Hospitals and Related Institutions (NACHRI); the six core competency domains mandated by the Accrediting Council on Graduate Medical Education (ACGME), the American Board of Pediatrics (ABP), and hospital medical staff offices as part of Focused Professional Practice Evaluation (FPPE) and Ongoing Professional Practice Evaluation (OPPE)16; and assessment of responsibilities and leadership roles fulfilled by pediatric hospitalists in all venues. In keeping with the intent of the competencies to be timeless, the competency elements call out the need to attend to the changing goals of these groups as well as those of the Institute of Healthcare Improvement (IHI), the Alliance for Pediatric Quality (which consists of ABP, AAP, TJC, CHCA, NACHRI), and local hospital systems leaders.

Contributors and Review

The CCTF selected section (associate) editors from SHM based on established expertise in each area, with input from the SHM Pediatric and Education Committees and the SHM Board. As a collaborative effort, authors for various chapters were solicited in consultation with experts from the AAP, APA, and SHM, and included non‐hospitalists with reputations as experts in various fields. Numerous SHM Pediatric Committee and CCTF conference calls were held to review hospital and academic appointments, presentations given, and affiliations relevant to the practice of pediatric hospital medicine. This vetting process resulted in a robust author list representing diverse geographic and practice settings. Contributors were provided with structure (Knowledge, Skills, Attitudes, and Systems subsections) and content (timeless, competency based) guidelines.

The review process was rigorous, and included both internal and external reviewers. The APA review in 2007 included the PHM Special Interest Group as well as the PHM Fellowship Directors (Table 1). After return to SHM and further editing, the internal review commenced which focused on content and scope. The editors addressed the resulting suggestions and worked to standardize formatting and use of Bloom's taxonomy.19 A list of common terms and phrases were created to add consistency between chapters. External reviewers were first mailed a letter requesting interest, which was followed up by emails, letters, and phone calls to encourage feedback. External review included 29 solicited agencies and societies (Table 3), with overall response rate of 66% (41% for Groups I and II). Individual contributors then reviewed comments specific to their chapters, with associate editor overview of their respective sections. The editors reviewed each chapter individually multiple times throughout the 2007‐2009 years, contacting individual contributors and reviewers by email and phone. Editors concluded a final comprehensive review of all chapters in late 2009.

Chapter Content

Each of the 54 chapters within the four sections of these competencies is presented in the educational theory of learning domains: Knowledge, Skills, Attitudes, with a final Systems domain added to reflect the emphasis of hospitalist practice on improving healthcare systems. Each chapter is designed to stand alone, which may assist with development of curriculum at individual practice locations. Certain key phrases are apparent throughout, such as lead, coordinate, or participate in and work with hospital and community leaders to which were designed to note the varied roles in different practice settings. Some chapters specifically comment on the application of competency bullets given the unique and differing roles and expectations of pediatric hospitalists, such as research and education. Chapters state specific proficiencies expected wherever possible, with phrases and wording selected to help guide learning activities to achieve the competency.

Application and Future Directions

Although pediatric hospitalists care for children in many settings, these core competencies address the common expectations for any venue. Pediatric hospital medicine requires skills in acute care clinical medicine that attend to the changing needs of hospitalized children. The core of pediatric hospital medicine is dedicated to the care of children in the geographic hospital environment between emergency medicine and tertiary pediatric and neonatal intensive care units. Pediatric hospitalists provide care in related clinical service programs that are linked to hospital systems. In performing these activities, pediatric hospitalists consistently partner with ambulatory providers and subspecialists to render coordinated care across the continuum for a given child. Pediatric hospital medicine is an interdisciplinary practice, with focus on processes of care and clinical quality outcomes based in evidence. Engagement in local, state, and national initiatives to improve child health outcomes is a cornerstone of pediatric hospitalists' practice. These competencies provide the framework for creation of curricula that can reflect local issues and react to changing evidence.

As providers of systems‐based care, pediatric hospitalists are called upon more and more to render care and provide leadership in clinical arenas that are integral to healthcare organizations, such as home health care, sub‐acute care facilities, and hospice and palliative care programs. The practice of pediatric hospital medicine has evolved to its current state through efforts of many represented in the competencies as contributors, associate editors, editors, and reviewers. Pediatric hospitalists are committed to leading change in healthcare for hospitalized children, and are positioned well to address the interests and needs of community and urban, teaching and non‐teaching facilities, and the children and families they serve. These competencies reflect the areas of focused practice which, similar to pediatric emergency medicine, will no doubt be refined but not fundamentally changed in future years. The intent, we hope, is clear: to provide excellence in clinical care, accountability for practice, and lead improvements in healthcare for hospitalized children.

Introduction

The Society of Hospital Medicine (SHM) defines hospitalists as physicians whose primary professional focus is the comprehensive general medical care of hospitalized patients. Their activities include patient care, teaching, research, and leadership related to Hospital Medicine.1 It is estimated that there are up to 2500 pediatric hospitalists in the United States, with continued growth due to the converging needs for a dedicated focus on patient safety, quality improvement, hospital throughput, and inpatient teaching.2‐9 (Pediatric Hospital Medicine (PHM), as defined today, has been practiced in the United States for at least 30 years10 and continues to evolve as an area of specialization, with the refinement of a distinct knowledgebase and skill set focused on the provision of high quality general pediatric care in the inpatient setting. PHM is the latest site‐specific specialty to emerge from the field of general pediatrics it's development analogous to the evolution of critical care or emergency medicine during previous decades.11 Adult hospital medicine has defined itself within the field of general internal medicine12 and has recently received approval to provide a recognized focus of practice exam in 2010 for those re‐certifying with the American Board of Internal Medicine,13 PHM is creating an identity as a subspecialty practice with distinct focus on inpatient care for children within the larger context of general pediatric care.8, 14

The Pediatric Hospital Medicine Core Competencies were created to help define the roles and expectations for pediatric hospitalists, regardless of practice setting. The intent is to provide a unified approach toward identifying the specific body of knowledge and measurable skills needed to assure delivery of the highest quality of care for all hospitalized pediatric patients. Most children requiring hospitalization in the United States are hospitalized in community settings where subspecialty support is more limited and many pediatric services may be unavailable. Children with complex, chronic medical problems, however, are more likely to be hospitalized at a tertiary care or academic institutions. In order to unify pediatric hospitalists who work in different practice environments, the PHM Core Competencies were constructed to represent the knowledge, skills, attitudes, and systems improvements that all pediatric hospitalists can be expected to acquire and maintain.

Furthermore, the content of the PHM Core Competencies reflect the fact that children are a vulnerable population. Their care requires attention to many elements which distinguishes it from that given to the majority of the adult population: dependency, differences in developmental physiology and behavior, occurrence of congenital genetic disorders and age‐based clinical conditions, impact of chronic disease states on whole child development, and weight‐based medication dosing often with limited guidance from pediatric studies, to name a few. Awareness of these needs must be heightened when a child enters the hospital where diagnoses, procedures, and treatments often include use of high‐risk modalities and require coordination of care across multiple providers.

Pediatric hospitalists commonly work to improve the systems of care in which they operate and therefore both clinical and non‐clinical topics are included. The 54 chapters address the fundamental and most common components of inpatient care but are not an extensive review of all aspects of inpatient medicine encountered by those caring for hospitalized children. Finally, the PHM Core Competencies are not intended for use in assessing proficiency immediately post‐residency, but do provide a framework for the education and evaluation of both physicians‐in‐training and practicing hospitalists. Meeting these competencies is anticipated to take from one to three years of active practice in pediatric hospital medicine, and may be reached through a combination of practice experience, course work, self‐directed work, and/or formalized training.

Methods

Areas of Focused Practice

The PHM Core Competencies were conceptualized similarly to the SHM adult core competencies. Initial sections were divided into clinical conditions, procedures, and systems. However as content developed and reviewer comments were addressed, the four final sections were modified to those noted in Table 2. For the Common Clinical Diagnoses and Conditions, the goal was to select conditions most commonly encountered by pediatric hospitalists. Non‐surgical diagnosis‐related group (DRG) conditions were selected from the following sources: The Joint Commission's (TJC) Oryx Performance Measures Report15‐16 (asthma, abdominal pain, acute gastroenteritis, simple pneumonia); Child Health Corporation of America's Pediatric Health Information System Dataset (CHCA PHIS, Shawnee Mission, KS), and relevant publications on common pediatric hospitalizations.17 These data were compared to billing data from randomly‐selected practicing hospitalists representing free‐standing children's and community hospitals, teaching and non‐teaching settings, and urban and rural locations. The 22 clinical conditions chosen by the CCTF were those most relevant to the practice of pediatric hospital medicine.

The Specialized Clinical Servicessection addresses important components of care that are not DRG‐based and reflect the unique needs of hospitalized children, as assessed by the CCTF, editors, and contributors. Core Skillswere chosen based on the HCUP Factbook 2 Procedures,18 billing data from randomly‐selected practicing hospitalists representing the same settings listed above, and critical input from reviewers. Depending on the individual setting, pediatric hospitalists may require skills in areas not found in these 11 chapters, such as chest tube placement or ventilator management. The list is therefore not exhaustive, but rather representative of skills most pediatric hospitalists should maintain.

The Healthcare Systems: Supporting and Advancing Child Healthchapters are likely the most dissimilar to any core content taught in traditional residency programs. While residency graduates are versed in some components listed in these chapters, comprehensive education in most of these competencies is currently lacking. Improvement of healthcare systems is an essential element of pediatric hospital medicine, and unifies all pediatric hospitalists regardless of practice environment or patient population. Therefore, this section includes chapters that not only focus on systems of care, but also on advancing child health through advocacy, research, education, evidence‐based medicine, and ethical practice. These chapters were drawn from a combination of several sources: expectations of external agencies (TJC, Center for Medicaid and Medicare) related to the specific nonclinical work in which pediatric hospitalists are integrally involved; expectations for advocacy as best defined by the AAP and the National Association of Children's Hospitals and Related Institutions (NACHRI); the six core competency domains mandated by the Accrediting Council on Graduate Medical Education (ACGME), the American Board of Pediatrics (ABP), and hospital medical staff offices as part of Focused Professional Practice Evaluation (FPPE) and Ongoing Professional Practice Evaluation (OPPE)16; and assessment of responsibilities and leadership roles fulfilled by pediatric hospitalists in all venues. In keeping with the intent of the competencies to be timeless, the competency elements call out the need to attend to the changing goals of these groups as well as those of the Institute of Healthcare Improvement (IHI), the Alliance for Pediatric Quality (which consists of ABP, AAP, TJC, CHCA, NACHRI), and local hospital systems leaders.

Contributors and Review

The CCTF selected section (associate) editors from SHM based on established expertise in each area, with input from the SHM Pediatric and Education Committees and the SHM Board. As a collaborative effort, authors for various chapters were solicited in consultation with experts from the AAP, APA, and SHM, and included non‐hospitalists with reputations as experts in various fields. Numerous SHM Pediatric Committee and CCTF conference calls were held to review hospital and academic appointments, presentations given, and affiliations relevant to the practice of pediatric hospital medicine. This vetting process resulted in a robust author list representing diverse geographic and practice settings. Contributors were provided with structure (Knowledge, Skills, Attitudes, and Systems subsections) and content (timeless, competency based) guidelines.

The review process was rigorous, and included both internal and external reviewers. The APA review in 2007 included the PHM Special Interest Group as well as the PHM Fellowship Directors (Table 1). After return to SHM and further editing, the internal review commenced which focused on content and scope. The editors addressed the resulting suggestions and worked to standardize formatting and use of Bloom's taxonomy.19 A list of common terms and phrases were created to add consistency between chapters. External reviewers were first mailed a letter requesting interest, which was followed up by emails, letters, and phone calls to encourage feedback. External review included 29 solicited agencies and societies (Table 3), with overall response rate of 66% (41% for Groups I and II). Individual contributors then reviewed comments specific to their chapters, with associate editor overview of their respective sections. The editors reviewed each chapter individually multiple times throughout the 2007‐2009 years, contacting individual contributors and reviewers by email and phone. Editors concluded a final comprehensive review of all chapters in late 2009.

Chapter Content

Each of the 54 chapters within the four sections of these competencies is presented in the educational theory of learning domains: Knowledge, Skills, Attitudes, with a final Systems domain added to reflect the emphasis of hospitalist practice on improving healthcare systems. Each chapter is designed to stand alone, which may assist with development of curriculum at individual practice locations. Certain key phrases are apparent throughout, such as lead, coordinate, or participate in and work with hospital and community leaders to which were designed to note the varied roles in different practice settings. Some chapters specifically comment on the application of competency bullets given the unique and differing roles and expectations of pediatric hospitalists, such as research and education. Chapters state specific proficiencies expected wherever possible, with phrases and wording selected to help guide learning activities to achieve the competency.

Application and Future Directions

Although pediatric hospitalists care for children in many settings, these core competencies address the common expectations for any venue. Pediatric hospital medicine requires skills in acute care clinical medicine that attend to the changing needs of hospitalized children. The core of pediatric hospital medicine is dedicated to the care of children in the geographic hospital environment between emergency medicine and tertiary pediatric and neonatal intensive care units. Pediatric hospitalists provide care in related clinical service programs that are linked to hospital systems. In performing these activities, pediatric hospitalists consistently partner with ambulatory providers and subspecialists to render coordinated care across the continuum for a given child. Pediatric hospital medicine is an interdisciplinary practice, with focus on processes of care and clinical quality outcomes based in evidence. Engagement in local, state, and national initiatives to improve child health outcomes is a cornerstone of pediatric hospitalists' practice. These competencies provide the framework for creation of curricula that can reflect local issues and react to changing evidence.

As providers of systems‐based care, pediatric hospitalists are called upon more and more to render care and provide leadership in clinical arenas that are integral to healthcare organizations, such as home health care, sub‐acute care facilities, and hospice and palliative care programs. The practice of pediatric hospital medicine has evolved to its current state through efforts of many represented in the competencies as contributors, associate editors, editors, and reviewers. Pediatric hospitalists are committed to leading change in healthcare for hospitalized children, and are positioned well to address the interests and needs of community and urban, teaching and non‐teaching facilities, and the children and families they serve. These competencies reflect the areas of focused practice which, similar to pediatric emergency medicine, will no doubt be refined but not fundamentally changed in future years. The intent, we hope, is clear: to provide excellence in clinical care, accountability for practice, and lead improvements in healthcare for hospitalized children.

Introduction

Asthma is the most common childhood chronic disease and is the third leading cause of hospital admission for children less than 15 years of age. Prevalence and mortality rates have increased over the past decade, along with costs, the latter predominantly associated with hospital based care. The Department of Health and Human Services (DHHS), through the National Institutes of Health (NIH), coordinated the National Asthma Education and Prevention Program designed to provide up‐to‐date evidence‐based guidelines for the diagnosis, treatment and prevention of asthma. The DHHS also identified asthma as one of the key elements of the Healthy People 2010 initiative with several specific health objectives related directly to inpatient management. Due to the chronic nature of this disease, pediatric hospitalists should not only treat the acute exacerbation resulting in status asthmaticus, but also create or re‐affirm long term management plans.

Knowledge

Pediatric hospitalists should be able to:

• Discuss the pathophysiology of asthma addressing both bronchoconstrictive and inflammatory components and state how each impacts pharmacologic treatment choices.

• Compare and contrast the pathophysiology of asthma with other common small airway illnesses in children such as bronchiolitis, viral pneumonia with bronchospasm, or chronic lung disease.

• List the differential diagnosis of wheezing for various age groups and delineate the defining features leading to a diagnosis of asthma.

• Summarize evaluation, monitoring, and treatment options for patients with worsening cardiorespiratory status including mental status assessment, capnography, inhaled and intravenous medications, respiratory support and others.

• Describe the signs and symptoms of impending respiratory failure and list criteria for transfer to an intensive care unit.

• Cite the common complications of asthma or asthma treatment, including pneumothorax, atelectasis, lobar collapse, poor cardiac output, dysrhythmias and others.

• State the basic pharmacology, safety profile and potential adverse effects of commonly used medications.

• Discuss the impact of risk factors (such as genetic predisposition and family history) associated chronic co‐morbidities (such as atopic dermatitis and allergic rhinitis) and exacerbating factors (such as gastroesophageal reflux and smoke exposure) on morbidity, treatment and prognosis.

• Define asthma groups by symptom severity and frequency based on current classification guidelines.

• Explain the significance of environmental controls and trigger avoidance in minimizing asthma exacerbations.

• Describe the utility of using asthma action plans to both monitor and treat asthma via pulmonary function testing (spirometry and/or peak flow) and proper use of controller and reliever medications.

• Discuss the goals of asthma management, including the maintenance of normal activity levels and pulmonary function, the prevention of chronic symptoms, recurrent exacerbations, and hospitalizations, and the provision of optimal pharmacotherapy while minimizing adverse events.

• Give examples of specific indications for referral to an asthma subspecialist.

• Illustrate why proper coding for asthma is critical to assure proper local resource use, accurate billing, and appropriate national comparisons of asthma data.

Skills

Pediatric hospitalists should be able to:

• Correctly diagnose and classify asthma by efficiently performing an accurate history and physical examination.

• Recognize signs and symptoms of serious complications of asthma such as pneumothorax or impending respiratory failure.

• Direct an evidence‐based treatment plan for status asthmaticus.

• Order and interpret objective measures of pulmonary function, including peak flow monitoring and spirometry.

• Order and interpret results of basic diagnostic tools such as chest radiograph and blood gas as indicated.

• Order appropriate monitoring and correctly interpret monitor data.

• Provide supplemental oxygen therapy and advanced airway management as necessary.

• Recognize indications for hospital admission and discharge, and for transfer to a higher level of care or tertiary care facility.

• Modify the medication regimen based upon accurate assessment of changes in disease severity.

• Efficiently render care by creating a discharge plan which can be expediently activated when appropriate.

• Consistently initiate patient and family/caregiver asthma education as soon after admission as possible, as appropriate for the clinical context.

• Coordinate care with the primary care provider including discharge medications and instructions, and follow‐up plans.

• Complete a written asthma action plan and use it to educate patients and the family/caregiver on trigger avoidance, medication adherence, and disease control.

Attitudes

Pediatric hospitalists should be able to:

• Reinforce the role and responsibility of patients and the family/caregiver regarding self‐care, recognition of symptoms, and disease management.

• Communicate effectively with patients, the family/caregiver and healthcare providers regarding care plans.

• Engage in a multi‐disciplinary approach to the prevention, diagnosis, and treatment of asthma, involving when appropriate, social workers or case managers, respiratory therapists, and subspecialists.

• Collaborate with primary care providers and subspecialists to ensure coordinated longitudinal care for children with asthma.

Systems Organization and Improvement

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

• Lead, coordinate or participate in local and national initiatives to further the development and implementation of evidence‐based clinical guidelines to promote effective resource utilization and improve quality of care for hospitalized children with asthma.

• Work with hospital administrators to implement and utilize performance feedback and quality improvement measures to assess outcomes of instituted guidelines for the management of inpatient asthma.

• Collaborate with primary care providers, subspecialists, social workers, and case managers to ensure a smooth transition to the outpatient setting, and to minimize the need for readmission.

Introduction

Asthma is the most common childhood chronic disease and is the third leading cause of hospital admission for children less than 15 years of age. Prevalence and mortality rates have increased over the past decade, along with costs, the latter predominantly associated with hospital based care. The Department of Health and Human Services (DHHS), through the National Institutes of Health (NIH), coordinated the National Asthma Education and Prevention Program designed to provide up‐to‐date evidence‐based guidelines for the diagnosis, treatment and prevention of asthma. The DHHS also identified asthma as one of the key elements of the Healthy People 2010 initiative with several specific health objectives related directly to inpatient management. Due to the chronic nature of this disease, pediatric hospitalists should not only treat the acute exacerbation resulting in status asthmaticus, but also create or re‐affirm long term management plans.

Knowledge

Pediatric hospitalists should be able to:

• Discuss the pathophysiology of asthma addressing both bronchoconstrictive and inflammatory components and state how each impacts pharmacologic treatment choices.

• Compare and contrast the pathophysiology of asthma with other common small airway illnesses in children such as bronchiolitis, viral pneumonia with bronchospasm, or chronic lung disease.

• List the differential diagnosis of wheezing for various age groups and delineate the defining features leading to a diagnosis of asthma.

• Summarize evaluation, monitoring, and treatment options for patients with worsening cardiorespiratory status including mental status assessment, capnography, inhaled and intravenous medications, respiratory support and others.

• Describe the signs and symptoms of impending respiratory failure and list criteria for transfer to an intensive care unit.

• Cite the common complications of asthma or asthma treatment, including pneumothorax, atelectasis, lobar collapse, poor cardiac output, dysrhythmias and others.

• State the basic pharmacology, safety profile and potential adverse effects of commonly used medications.

• Discuss the impact of risk factors (such as genetic predisposition and family history) associated chronic co‐morbidities (such as atopic dermatitis and allergic rhinitis) and exacerbating factors (such as gastroesophageal reflux and smoke exposure) on morbidity, treatment and prognosis.

• Define asthma groups by symptom severity and frequency based on current classification guidelines.

• Explain the significance of environmental controls and trigger avoidance in minimizing asthma exacerbations.

• Describe the utility of using asthma action plans to both monitor and treat asthma via pulmonary function testing (spirometry and/or peak flow) and proper use of controller and reliever medications.

• Discuss the goals of asthma management, including the maintenance of normal activity levels and pulmonary function, the prevention of chronic symptoms, recurrent exacerbations, and hospitalizations, and the provision of optimal pharmacotherapy while minimizing adverse events.

• Give examples of specific indications for referral to an asthma subspecialist.

• Illustrate why proper coding for asthma is critical to assure proper local resource use, accurate billing, and appropriate national comparisons of asthma data.

Skills

Pediatric hospitalists should be able to:

• Correctly diagnose and classify asthma by efficiently performing an accurate history and physical examination.

• Recognize signs and symptoms of serious complications of asthma such as pneumothorax or impending respiratory failure.

• Direct an evidence‐based treatment plan for status asthmaticus.

• Order and interpret objective measures of pulmonary function, including peak flow monitoring and spirometry.

• Order and interpret results of basic diagnostic tools such as chest radiograph and blood gas as indicated.

• Order appropriate monitoring and correctly interpret monitor data.

• Provide supplemental oxygen therapy and advanced airway management as necessary.

• Recognize indications for hospital admission and discharge, and for transfer to a higher level of care or tertiary care facility.

• Modify the medication regimen based upon accurate assessment of changes in disease severity.

• Efficiently render care by creating a discharge plan which can be expediently activated when appropriate.

• Consistently initiate patient and family/caregiver asthma education as soon after admission as possible, as appropriate for the clinical context.

• Coordinate care with the primary care provider including discharge medications and instructions, and follow‐up plans.

• Complete a written asthma action plan and use it to educate patients and the family/caregiver on trigger avoidance, medication adherence, and disease control.

Attitudes

Pediatric hospitalists should be able to:

• Reinforce the role and responsibility of patients and the family/caregiver regarding self‐care, recognition of symptoms, and disease management.

• Communicate effectively with patients, the family/caregiver and healthcare providers regarding care plans.

• Engage in a multi‐disciplinary approach to the prevention, diagnosis, and treatment of asthma, involving when appropriate, social workers or case managers, respiratory therapists, and subspecialists.

• Collaborate with primary care providers and subspecialists to ensure coordinated longitudinal care for children with asthma.

Systems Organization and Improvement

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

• Lead, coordinate or participate in local and national initiatives to further the development and implementation of evidence‐based clinical guidelines to promote effective resource utilization and improve quality of care for hospitalized children with asthma.

• Work with hospital administrators to implement and utilize performance feedback and quality improvement measures to assess outcomes of instituted guidelines for the management of inpatient asthma.

• Collaborate with primary care providers, subspecialists, social workers, and case managers to ensure a smooth transition to the outpatient setting, and to minimize the need for readmission.

Introduction

Asthma is the most common childhood chronic disease and is the third leading cause of hospital admission for children less than 15 years of age. Prevalence and mortality rates have increased over the past decade, along with costs, the latter predominantly associated with hospital based care. The Department of Health and Human Services (DHHS), through the National Institutes of Health (NIH), coordinated the National Asthma Education and Prevention Program designed to provide up‐to‐date evidence‐based guidelines for the diagnosis, treatment and prevention of asthma. The DHHS also identified asthma as one of the key elements of the Healthy People 2010 initiative with several specific health objectives related directly to inpatient management. Due to the chronic nature of this disease, pediatric hospitalists should not only treat the acute exacerbation resulting in status asthmaticus, but also create or re‐affirm long term management plans.

Knowledge

Pediatric hospitalists should be able to:

• Discuss the pathophysiology of asthma addressing both bronchoconstrictive and inflammatory components and state how each impacts pharmacologic treatment choices.

• Compare and contrast the pathophysiology of asthma with other common small airway illnesses in children such as bronchiolitis, viral pneumonia with bronchospasm, or chronic lung disease.

• List the differential diagnosis of wheezing for various age groups and delineate the defining features leading to a diagnosis of asthma.

• Summarize evaluation, monitoring, and treatment options for patients with worsening cardiorespiratory status including mental status assessment, capnography, inhaled and intravenous medications, respiratory support and others.

• Describe the signs and symptoms of impending respiratory failure and list criteria for transfer to an intensive care unit.

• Cite the common complications of asthma or asthma treatment, including pneumothorax, atelectasis, lobar collapse, poor cardiac output, dysrhythmias and others.

• State the basic pharmacology, safety profile and potential adverse effects of commonly used medications.

• Discuss the impact of risk factors (such as genetic predisposition and family history) associated chronic co‐morbidities (such as atopic dermatitis and allergic rhinitis) and exacerbating factors (such as gastroesophageal reflux and smoke exposure) on morbidity, treatment and prognosis.

• Define asthma groups by symptom severity and frequency based on current classification guidelines.

• Explain the significance of environmental controls and trigger avoidance in minimizing asthma exacerbations.

• Describe the utility of using asthma action plans to both monitor and treat asthma via pulmonary function testing (spirometry and/or peak flow) and proper use of controller and reliever medications.

• Discuss the goals of asthma management, including the maintenance of normal activity levels and pulmonary function, the prevention of chronic symptoms, recurrent exacerbations, and hospitalizations, and the provision of optimal pharmacotherapy while minimizing adverse events.

• Give examples of specific indications for referral to an asthma subspecialist.

• Illustrate why proper coding for asthma is critical to assure proper local resource use, accurate billing, and appropriate national comparisons of asthma data.

Skills

Pediatric hospitalists should be able to:

• Correctly diagnose and classify asthma by efficiently performing an accurate history and physical examination.

• Recognize signs and symptoms of serious complications of asthma such as pneumothorax or impending respiratory failure.

• Direct an evidence‐based treatment plan for status asthmaticus.

• Order and interpret objective measures of pulmonary function, including peak flow monitoring and spirometry.

• Order and interpret results of basic diagnostic tools such as chest radiograph and blood gas as indicated.

• Order appropriate monitoring and correctly interpret monitor data.

• Provide supplemental oxygen therapy and advanced airway management as necessary.

• Recognize indications for hospital admission and discharge, and for transfer to a higher level of care or tertiary care facility.

• Modify the medication regimen based upon accurate assessment of changes in disease severity.

• Efficiently render care by creating a discharge plan which can be expediently activated when appropriate.

• Consistently initiate patient and family/caregiver asthma education as soon after admission as possible, as appropriate for the clinical context.

• Coordinate care with the primary care provider including discharge medications and instructions, and follow‐up plans.

• Complete a written asthma action plan and use it to educate patients and the family/caregiver on trigger avoidance, medication adherence, and disease control.

Attitudes

Pediatric hospitalists should be able to:

• Reinforce the role and responsibility of patients and the family/caregiver regarding self‐care, recognition of symptoms, and disease management.

• Communicate effectively with patients, the family/caregiver and healthcare providers regarding care plans.

• Engage in a multi‐disciplinary approach to the prevention, diagnosis, and treatment of asthma, involving when appropriate, social workers or case managers, respiratory therapists, and subspecialists.

• Collaborate with primary care providers and subspecialists to ensure coordinated longitudinal care for children with asthma.

Systems Organization and Improvement

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

• Lead, coordinate or participate in local and national initiatives to further the development and implementation of evidence‐based clinical guidelines to promote effective resource utilization and improve quality of care for hospitalized children with asthma.

• Work with hospital administrators to implement and utilize performance feedback and quality improvement measures to assess outcomes of instituted guidelines for the management of inpatient asthma.

• Collaborate with primary care providers, subspecialists, social workers, and case managers to ensure a smooth transition to the outpatient setting, and to minimize the need for readmission.

Introduction

The delivery of cost‐effective care is an important responsibility and necessary skill for pediatric hospitalists. In the United States, hospital care for children, including neonatal conditions, pediatric illness and adolescent pregnancy entails 6.3 million hospital stays and $46 billion in charges per year. Pediatric inpatient care accounts for 18% of all hospital days and 9% of total U.S. hospital charges. Of these,, three respiratory conditions ‐ pneumonia, bronchitis and asthma ‐ are responsible for nearly $3 billion in charges or 7% of the total US health care bill for children and adolescents Although some categories of hospital expenses such as nurses or equipment may be outside the control of physicians, there are a number that are driven by physician practice patterns. Physician influence on hospital costs is exerted primarily through hospital length stay, medication prescribing patterns, and utilization of laboratory and diagnostic imaging services. Pediatric hospitalists can make a significant contribution to cost management efforts by increased awareness, standardization, evaluation and modification of practice and utilization patterns.

Knowledge

Pediatric hospitalists should be able to:

• List the various methods of financing health care for children and state the implications of each on patient care.

• Identify and discuss the importance of the metrics used to describe hospital costs such as charges, length of stay, cost per case, and hospital expense per adjusted day.

• Demonstrate knowledge of common payment mechanisms for hospital care such as case rates, percent of charges, observation status, per diem rates, and capitation.

• Describe mechanisms used by health plans and hospitals to limit hospital costs including pre‐authorization and utilization review.

• Name hospital care costs that are controllable by physicians.

• Identify examples of how standardization of clinical care processes improves cost and quality of care.

• Discuss recent trends in health care delivery that affect pediatric practice such as coordinated management of complex chronic diseases and development of integrated delivery systems.

• Describe the concept of system integration and define the roles of various components of the health care system such as community health centers, academic health centers, private practices, and home care agencies.

• Define the role of major federal health programs such as Medicaid, Women Infants and Children (WIC) and Vaccines for Children (VFC) in funding healthcare to children from low‐income households.

• Give an example of differences in costs of commonly prescribed medications. Illustrate the importance of various considerations when prescribing drugs such as total cost, compliance, availability of pediatric formulation, and insurance formulary lists.

Skills

Pediatric hospitalists should be able to:

• Apply strategies to control costs in the daily care of patients in the hospital, such as use of generic drugs, case management, and avoidance of ordering unnecessary tests, as appropriate.

• Participate in hospital committees where finance and clinical care are discussed such as pharmacy and therapeutics, quality improvement, ambulatory access, and others.

• Incorporate cost considerations when writing orders, and use these opportunities to educate trainees on the importance of such considerations.

• Obtain information about costs of care including drugs, medical imaging, and devices.

• Work with consultants to determine cost effective approaches to testing and treatment plans.

• Coordinate the care of patients to reduce redundant testing or procedures.

• Work effectively with home care, discharge planning nurses, care coordinators, and case managers to ensure timely and safe hospital discharge.

• Provide education for patients and the family/caregiver that promotes an awareness of costs in developing treatment and discharge plans.

• Develop and utilize metrics and performance reporting (such as medication usage) to improve delivery of cost effective care.

Attitudes

Pediatric hospitalists should be able to:

• Assume personal responsibility for providing cost effective care.

• Serve as an advocate among professional colleagues and in the community for methods to reduce costs of care.

• Work collaboratively with others to continuously evaluate and improve care while reducing costs.

Systems Organization and Improvement

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

• Support efforts to gather and disseminate cost, quality and safety data for use in monitoring quality and business improvement efforts.

• Promote standard methods of clinical care that improve cost, quality and patient safety.

• Work to develop benchmarks for best practices in cost effective care.

• Collaborate with hospital administrators to determine and direct policies that impact healthcare utilization.

Introduction

The delivery of cost‐effective care is an important responsibility and necessary skill for pediatric hospitalists. In the United States, hospital care for children, including neonatal conditions, pediatric illness and adolescent pregnancy entails 6.3 million hospital stays and $46 billion in charges per year. Pediatric inpatient care accounts for 18% of all hospital days and 9% of total U.S. hospital charges. Of these,, three respiratory conditions ‐ pneumonia, bronchitis and asthma ‐ are responsible for nearly $3 billion in charges or 7% of the total US health care bill for children and adolescents Although some categories of hospital expenses such as nurses or equipment may be outside the control of physicians, there are a number that are driven by physician practice patterns. Physician influence on hospital costs is exerted primarily through hospital length stay, medication prescribing patterns, and utilization of laboratory and diagnostic imaging services. Pediatric hospitalists can make a significant contribution to cost management efforts by increased awareness, standardization, evaluation and modification of practice and utilization patterns.

Knowledge

Pediatric hospitalists should be able to:

• List the various methods of financing health care for children and state the implications of each on patient care.

• Identify and discuss the importance of the metrics used to describe hospital costs such as charges, length of stay, cost per case, and hospital expense per adjusted day.

• Demonstrate knowledge of common payment mechanisms for hospital care such as case rates, percent of charges, observation status, per diem rates, and capitation.

• Describe mechanisms used by health plans and hospitals to limit hospital costs including pre‐authorization and utilization review.

• Name hospital care costs that are controllable by physicians.

• Identify examples of how standardization of clinical care processes improves cost and quality of care.

• Discuss recent trends in health care delivery that affect pediatric practice such as coordinated management of complex chronic diseases and development of integrated delivery systems.

• Describe the concept of system integration and define the roles of various components of the health care system such as community health centers, academic health centers, private practices, and home care agencies.

• Define the role of major federal health programs such as Medicaid, Women Infants and Children (WIC) and Vaccines for Children (VFC) in funding healthcare to children from low‐income households.

• Give an example of differences in costs of commonly prescribed medications. Illustrate the importance of various considerations when prescribing drugs such as total cost, compliance, availability of pediatric formulation, and insurance formulary lists.

Skills

Pediatric hospitalists should be able to:

• Apply strategies to control costs in the daily care of patients in the hospital, such as use of generic drugs, case management, and avoidance of ordering unnecessary tests, as appropriate.

• Participate in hospital committees where finance and clinical care are discussed such as pharmacy and therapeutics, quality improvement, ambulatory access, and others.

• Incorporate cost considerations when writing orders, and use these opportunities to educate trainees on the importance of such considerations.

• Obtain information about costs of care including drugs, medical imaging, and devices.

• Work with consultants to determine cost effective approaches to testing and treatment plans.

• Coordinate the care of patients to reduce redundant testing or procedures.

• Work effectively with home care, discharge planning nurses, care coordinators, and case managers to ensure timely and safe hospital discharge.

• Provide education for patients and the family/caregiver that promotes an awareness of costs in developing treatment and discharge plans.

• Develop and utilize metrics and performance reporting (such as medication usage) to improve delivery of cost effective care.

Attitudes

Pediatric hospitalists should be able to:

• Assume personal responsibility for providing cost effective care.

• Serve as an advocate among professional colleagues and in the community for methods to reduce costs of care.

• Work collaboratively with others to continuously evaluate and improve care while reducing costs.

Systems Organization and Improvement

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

• Support efforts to gather and disseminate cost, quality and safety data for use in monitoring quality and business improvement efforts.

• Promote standard methods of clinical care that improve cost, quality and patient safety.

• Work to develop benchmarks for best practices in cost effective care.

• Collaborate with hospital administrators to determine and direct policies that impact healthcare utilization.

Introduction

The delivery of cost‐effective care is an important responsibility and necessary skill for pediatric hospitalists. In the United States, hospital care for children, including neonatal conditions, pediatric illness and adolescent pregnancy entails 6.3 million hospital stays and $46 billion in charges per year. Pediatric inpatient care accounts for 18% of all hospital days and 9% of total U.S. hospital charges. Of these,, three respiratory conditions ‐ pneumonia, bronchitis and asthma ‐ are responsible for nearly $3 billion in charges or 7% of the total US health care bill for children and adolescents Although some categories of hospital expenses such as nurses or equipment may be outside the control of physicians, there are a number that are driven by physician practice patterns. Physician influence on hospital costs is exerted primarily through hospital length stay, medication prescribing patterns, and utilization of laboratory and diagnostic imaging services. Pediatric hospitalists can make a significant contribution to cost management efforts by increased awareness, standardization, evaluation and modification of practice and utilization patterns.

Knowledge

Pediatric hospitalists should be able to:

• List the various methods of financing health care for children and state the implications of each on patient care.

• Identify and discuss the importance of the metrics used to describe hospital costs such as charges, length of stay, cost per case, and hospital expense per adjusted day.

• Demonstrate knowledge of common payment mechanisms for hospital care such as case rates, percent of charges, observation status, per diem rates, and capitation.

• Describe mechanisms used by health plans and hospitals to limit hospital costs including pre‐authorization and utilization review.

• Name hospital care costs that are controllable by physicians.

• Identify examples of how standardization of clinical care processes improves cost and quality of care.

• Discuss recent trends in health care delivery that affect pediatric practice such as coordinated management of complex chronic diseases and development of integrated delivery systems.

• Describe the concept of system integration and define the roles of various components of the health care system such as community health centers, academic health centers, private practices, and home care agencies.

• Define the role of major federal health programs such as Medicaid, Women Infants and Children (WIC) and Vaccines for Children (VFC) in funding healthcare to children from low‐income households.

• Give an example of differences in costs of commonly prescribed medications. Illustrate the importance of various considerations when prescribing drugs such as total cost, compliance, availability of pediatric formulation, and insurance formulary lists.

Skills

Pediatric hospitalists should be able to:

• Apply strategies to control costs in the daily care of patients in the hospital, such as use of generic drugs, case management, and avoidance of ordering unnecessary tests, as appropriate.

• Participate in hospital committees where finance and clinical care are discussed such as pharmacy and therapeutics, quality improvement, ambulatory access, and others.

• Incorporate cost considerations when writing orders, and use these opportunities to educate trainees on the importance of such considerations.

• Obtain information about costs of care including drugs, medical imaging, and devices.

• Work with consultants to determine cost effective approaches to testing and treatment plans.

• Coordinate the care of patients to reduce redundant testing or procedures.

• Work effectively with home care, discharge planning nurses, care coordinators, and case managers to ensure timely and safe hospital discharge.

• Provide education for patients and the family/caregiver that promotes an awareness of costs in developing treatment and discharge plans.

• Develop and utilize metrics and performance reporting (such as medication usage) to improve delivery of cost effective care.

Attitudes

Pediatric hospitalists should be able to:

• Assume personal responsibility for providing cost effective care.

• Serve as an advocate among professional colleagues and in the community for methods to reduce costs of care.

• Work collaboratively with others to continuously evaluate and improve care while reducing costs.

Systems Organization and Improvement

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

• Support efforts to gather and disseminate cost, quality and safety data for use in monitoring quality and business improvement efforts.

• Promote standard methods of clinical care that improve cost, quality and patient safety.

• Work to develop benchmarks for best practices in cost effective care.

• Collaborate with hospital administrators to determine and direct policies that impact healthcare utilization.

Introduction

Bladder catheterization is a common procedure, typically used to collect a sterile urine sample for analysis and culture when urinary tract infection is suspected. Bladder catheterization is also used to relieve urinary retention or obstruction, particularly in cases of anatomic abnormalities or neurogenic bladder, or to monitor urine output and fluid status. Pediatric hospitalists frequently encounter patients requiring bladder catheterization and should be adept at performing this procedure in infants, children, and adolescents.

Knowledge

Pediatric hospitalists should be able to:

• List the indications and contraindications for bladder catheterization.

• Describe how the method used to collect a urine specimen can affect interpretation of urine culture results, and explain why bladder catheterization or suprapubic tap are the preferred methods of collection in infants and children that cannot reliably produce a voided specimen.

• Review the basic anatomy of the male and female genitourinary tract.

• Review the steps in performing bladder catheterization for both male and female patients, attending to aspects such as patient identification, sterile technique, positioning, equipment needs, and specimen handling.

• Discuss the indications for analgesia, sedation, or anxiolysis and describe the medications that may be used for each.

• Describe the risks and complications associated with bladder catheterization, such as localized trauma, creation of a false passage, and potential stricture formation.

• List the indications for consultation with a urologist with regard to bladder catheterization, including known genitourinary tract abnormality, recent genitourinary surgery, or urethral trauma

• Compare and contrast the effects of using various methods to collect a urine specimen, including interpretation of the culture and urinalysis and patient risk,

• Define a UTI as obtained by various methods such as catheterization, clean catch, clean bag, and suprapubic tap.

• Discuss the importance of appropriate specimen handling and the effect on culture results.

Skills

Pediatric hospitalists should be able to:

• Perform a pre‐procedural evaluation to determine risks and benefits of bladder catheterization.

• Demonstrate proficiency in performance of bladder catheterization on infants, children, and adolescents.

• Consider the level of pain and anxiety provoked by the procedure and provide appropriate pharmacologic or non‐pharmacologic interventions when indicated.

• Correctly identify the need for and efficiently offer education to healthcare providers on proper techniques for holding and calming patients before, during, and after bladder catheterization.

• Consistently adhere to infection control practices.

• Identify complications and respond with appropriate actions.

• Identify the need for and efficiently access appropriate consultants and support services for assistance with analgesia, sedation, anxiolysis, and performance of a bladder catheterization.

Attitudes

Hospital physicians should be able to:

• Recognize the importance of obtaining a sterile urine specimen in order to correctly diagnose urinary tract infection.

• Communicate effectively with patients and the family/caregiver regarding the indications for, risks, benefits, and steps of bladder catheterization.

• 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 bladder catheterization in children.

• Lead, coordinate or participate in the development and implementation of educational initiatives designed to teach the proper technique for bladder catheterization to learners and other healthcare providers.

Introduction

Bladder catheterization is a common procedure, typically used to collect a sterile urine sample for analysis and culture when urinary tract infection is suspected. Bladder catheterization is also used to relieve urinary retention or obstruction, particularly in cases of anatomic abnormalities or neurogenic bladder, or to monitor urine output and fluid status. Pediatric hospitalists frequently encounter patients requiring bladder catheterization and should be adept at performing this procedure in infants, children, and adolescents.

Knowledge

Pediatric hospitalists should be able to:

• List the indications and contraindications for bladder catheterization.

• Describe how the method used to collect a urine specimen can affect interpretation of urine culture results, and explain why bladder catheterization or suprapubic tap are the preferred methods of collection in infants and children that cannot reliably produce a voided specimen.

• Review the basic anatomy of the male and female genitourinary tract.

• Review the steps in performing bladder catheterization for both male and female patients, attending to aspects such as patient identification, sterile technique, positioning, equipment needs, and specimen handling.

• Discuss the indications for analgesia, sedation, or anxiolysis and describe the medications that may be used for each.

• Describe the risks and complications associated with bladder catheterization, such as localized trauma, creation of a false passage, and potential stricture formation.

• List the indications for consultation with a urologist with regard to bladder catheterization, including known genitourinary tract abnormality, recent genitourinary surgery, or urethral trauma

• Compare and contrast the effects of using various methods to collect a urine specimen, including interpretation of the culture and urinalysis and patient risk,

• Define a UTI as obtained by various methods such as catheterization, clean catch, clean bag, and suprapubic tap.

• Discuss the importance of appropriate specimen handling and the effect on culture results.

Skills

Pediatric hospitalists should be able to:

• Perform a pre‐procedural evaluation to determine risks and benefits of bladder catheterization.

• Demonstrate proficiency in performance of bladder catheterization on infants, children, and adolescents.

• Consider the level of pain and anxiety provoked by the procedure and provide appropriate pharmacologic or non‐pharmacologic interventions when indicated.

• Correctly identify the need for and efficiently offer education to healthcare providers on proper techniques for holding and calming patients before, during, and after bladder catheterization.

• Consistently adhere to infection control practices.

• Identify complications and respond with appropriate actions.

• Identify the need for and efficiently access appropriate consultants and support services for assistance with analgesia, sedation, anxiolysis, and performance of a bladder catheterization.

Attitudes

Hospital physicians should be able to:

• Recognize the importance of obtaining a sterile urine specimen in order to correctly diagnose urinary tract infection.

• Communicate effectively with patients and the family/caregiver regarding the indications for, risks, benefits, and steps of bladder catheterization.

• 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 bladder catheterization in children.

• Lead, coordinate or participate in the development and implementation of educational initiatives designed to teach the proper technique for bladder catheterization to learners and other healthcare providers.

Introduction

Bladder catheterization is a common procedure, typically used to collect a sterile urine sample for analysis and culture when urinary tract infection is suspected. Bladder catheterization is also used to relieve urinary retention or obstruction, particularly in cases of anatomic abnormalities or neurogenic bladder, or to monitor urine output and fluid status. Pediatric hospitalists frequently encounter patients requiring bladder catheterization and should be adept at performing this procedure in infants, children, and adolescents.

Knowledge

Pediatric hospitalists should be able to:

• List the indications and contraindications for bladder catheterization.

• Describe how the method used to collect a urine specimen can affect interpretation of urine culture results, and explain why bladder catheterization or suprapubic tap are the preferred methods of collection in infants and children that cannot reliably produce a voided specimen.

• Review the basic anatomy of the male and female genitourinary tract.

• Review the steps in performing bladder catheterization for both male and female patients, attending to aspects such as patient identification, sterile technique, positioning, equipment needs, and specimen handling.

• Discuss the indications for analgesia, sedation, or anxiolysis and describe the medications that may be used for each.

• Describe the risks and complications associated with bladder catheterization, such as localized trauma, creation of a false passage, and potential stricture formation.

• List the indications for consultation with a urologist with regard to bladder catheterization, including known genitourinary tract abnormality, recent genitourinary surgery, or urethral trauma

• Compare and contrast the effects of using various methods to collect a urine specimen, including interpretation of the culture and urinalysis and patient risk,

• Define a UTI as obtained by various methods such as catheterization, clean catch, clean bag, and suprapubic tap.

• Discuss the importance of appropriate specimen handling and the effect on culture results.

Skills

Pediatric hospitalists should be able to:

• Perform a pre‐procedural evaluation to determine risks and benefits of bladder catheterization.

• Demonstrate proficiency in performance of bladder catheterization on infants, children, and adolescents.

• Consider the level of pain and anxiety provoked by the procedure and provide appropriate pharmacologic or non‐pharmacologic interventions when indicated.

• Correctly identify the need for and efficiently offer education to healthcare providers on proper techniques for holding and calming patients before, during, and after bladder catheterization.

• Consistently adhere to infection control practices.

• Identify complications and respond with appropriate actions.

• Identify the need for and efficiently access appropriate consultants and support services for assistance with analgesia, sedation, anxiolysis, and performance of a bladder catheterization.

Attitudes

Hospital physicians should be able to:

• Recognize the importance of obtaining a sterile urine specimen in order to correctly diagnose urinary tract infection.

• Communicate effectively with patients and the family/caregiver regarding the indications for, risks, benefits, and steps of bladder catheterization.

• 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 bladder catheterization in children.

• Lead, coordinate or participate in the development and implementation of educational initiatives designed to teach the proper technique for bladder catheterization to learners and other healthcare providers.

Introduction

Research is a rapidly growing aspect of inpatient medicine. The practice of evidence‐based medicine and the acute need for more evidence on inpatient conditions require that pediatric hospitalists understand and participate in research related activities. Pediatric hospitalists' role in research will vary depending on their setting and job description. This role may include many facets, from reviewing relevant patient‐based articles, to participating in multi‐institutional studies requiring enrollment of patients, to leading local or national studies. Pediatric hospitalists need to have a basic understanding of research methods and process in order to participate in and benefit from research. This understanding contributes to the effective care of hospitalized patients.

Knowledge

Pediatric hospitalists should be able to:

• Compare and contrast different types of study design such as case‐control, cohort, observational, and randomized control trials. Understand the advantages and disadvantages of each study design.

• Name resources available to access current or proposed studies and funding sources such as the Agency for Healthcare Research and Quality (AHRQ), the National Institutes of Health (NIH), Robert Wood Johnson Foundation, clinicaltrials.gov, and others.

• Discuss what resources are required to support research components of data collection, data analysis, abstract and manuscript preparation, grant funding and others.

• Explain how results from articles published in the following formats apply to clinical practice:

   

  • Case reports and case series

  • Retrospective chart reviews

  • Secondary data analyses of large data sets

  • Randomized controlled trials

  • Meta analyses and systematic reviews

  • Practice Guidelines

  • Identify and efficiently locate the best available information resources to address questions in clinical practice, and conduct computerized scientific literature searches in a planned and systematic fashion.

  • Define basic statistical terms such as sample, discrete and continuous data variables, measures of central tendency (mean, median, and mode) and variability (variance, standard deviation, range).

  • Cite the various aspects of the research process including informed consent or assent, the role of institutional review boards (IRB), and HIPAA (Health Insurance Portability and Accountability Act).

  • Discuss special protections needed when conducting research with vulnerable populations. Define minimal risk for a healthy child and for a child with an illness.

  • List common barriers to implementation of clinical studies and describe pediatric hospitalists' role in overcoming these barriers.

   

Skills

Pediatric hospitalists should be able to:

• Demonstrate proficiency in searching the medical literature for existing relevant clinical research for their inpatients.

• Generate an answerable patient‐centered clinical question that is relevant to improving patient care.

• Apply the results of studies to clinical practice by determining whether the study subjects were similar to patients being treated, whether all clinically important outcomes were considered, identify threats to validity, and

   

  • For treatment studies, describe whether the likely benefits are worth the potential harm and cost.

  • For studies of diagnostic tests, describe whether the test is available, affordable, accurate and precise in the present clinical setting, and whether the results of the test will change the management of patients being treated.

  • For studies of harm, describe whether the magnitude of risk warrants an attempt to stop the exposure.

  • For studies of prognosis, describe whether the results of the study will lead directly to selecting therapy and/or are useful for counseling patients.

  • Provide effective informed consent or assent for patients participating in research studies as appropriate.

   

Attitudes

Pediatric hospitalists should be able to:

• Appreciate the importance of full informed consent for purposes of patient participation in clinical research.

• Appreciate the importance of patient assent, even in the presence of legal guardian informed consent, when involving children in clinical research.

• Demonstrate highly ethical principles in participating in research studies.

• Avoid conflict of interest or potential conflict of interest in participation in research studies.

• Acquire, manage, and share data collected for research purposes in a responsible and professional manner, maintaining high standards for protecting confidentiality, avoiding unjustified exclusions, sharing data, and adhering to copyright law.

Systems Organization and Improvement

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

• Encourage participation of interdisciplinary teams including nursing, social work, nutrition, pharmacy, and others in performance of research.

• Advocate for thoughtful application of research findings to improve systems of healthcare delivery.

• Support national multi‐center research efforts that improve the evidence base in inpatient pediatrics. Where appropriate, encourage participation local hospital involvement in these efforts.

• Recognize, support and promote efforts of research team members (analyst, data collector, statistician, nursing, and others).

Introduction

Research is a rapidly growing aspect of inpatient medicine. The practice of evidence‐based medicine and the acute need for more evidence on inpatient conditions require that pediatric hospitalists understand and participate in research related activities. Pediatric hospitalists' role in research will vary depending on their setting and job description. This role may include many facets, from reviewing relevant patient‐based articles, to participating in multi‐institutional studies requiring enrollment of patients, to leading local or national studies. Pediatric hospitalists need to have a basic understanding of research methods and process in order to participate in and benefit from research. This understanding contributes to the effective care of hospitalized patients.

Knowledge

Pediatric hospitalists should be able to:

• Compare and contrast different types of study design such as case‐control, cohort, observational, and randomized control trials. Understand the advantages and disadvantages of each study design.

• Name resources available to access current or proposed studies and funding sources such as the Agency for Healthcare Research and Quality (AHRQ), the National Institutes of Health (NIH), Robert Wood Johnson Foundation, clinicaltrials.gov, and others.

• Discuss what resources are required to support research components of data collection, data analysis, abstract and manuscript preparation, grant funding and others.

• Explain how results from articles published in the following formats apply to clinical practice:

   

  • Case reports and case series

  • Retrospective chart reviews

  • Secondary data analyses of large data sets

  • Randomized controlled trials

  • Meta analyses and systematic reviews

  • Practice Guidelines

  • Identify and efficiently locate the best available information resources to address questions in clinical practice, and conduct computerized scientific literature searches in a planned and systematic fashion.

  • Define basic statistical terms such as sample, discrete and continuous data variables, measures of central tendency (mean, median, and mode) and variability (variance, standard deviation, range).

  • Cite the various aspects of the research process including informed consent or assent, the role of institutional review boards (IRB), and HIPAA (Health Insurance Portability and Accountability Act).

  • Discuss special protections needed when conducting research with vulnerable populations. Define minimal risk for a healthy child and for a child with an illness.

  • List common barriers to implementation of clinical studies and describe pediatric hospitalists' role in overcoming these barriers.

   

Skills

Pediatric hospitalists should be able to:

• Demonstrate proficiency in searching the medical literature for existing relevant clinical research for their inpatients.

• Generate an answerable patient‐centered clinical question that is relevant to improving patient care.

• Apply the results of studies to clinical practice by determining whether the study subjects were similar to patients being treated, whether all clinically important outcomes were considered, identify threats to validity, and

   

  • For treatment studies, describe whether the likely benefits are worth the potential harm and cost.

  • For studies of diagnostic tests, describe whether the test is available, affordable, accurate and precise in the present clinical setting, and whether the results of the test will change the management of patients being treated.

  • For studies of harm, describe whether the magnitude of risk warrants an attempt to stop the exposure.

  • For studies of prognosis, describe whether the results of the study will lead directly to selecting therapy and/or are useful for counseling patients.

  • Provide effective informed consent or assent for patients participating in research studies as appropriate.

   

Attitudes

Pediatric hospitalists should be able to:

• Appreciate the importance of full informed consent for purposes of patient participation in clinical research.

• Appreciate the importance of patient assent, even in the presence of legal guardian informed consent, when involving children in clinical research.

• Demonstrate highly ethical principles in participating in research studies.

• Avoid conflict of interest or potential conflict of interest in participation in research studies.

• Acquire, manage, and share data collected for research purposes in a responsible and professional manner, maintaining high standards for protecting confidentiality, avoiding unjustified exclusions, sharing data, and adhering to copyright law.

Systems Organization and Improvement

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

• Encourage participation of interdisciplinary teams including nursing, social work, nutrition, pharmacy, and others in performance of research.

• Advocate for thoughtful application of research findings to improve systems of healthcare delivery.

• Support national multi‐center research efforts that improve the evidence base in inpatient pediatrics. Where appropriate, encourage participation local hospital involvement in these efforts.

• Recognize, support and promote efforts of research team members (analyst, data collector, statistician, nursing, and others).

Introduction

Research is a rapidly growing aspect of inpatient medicine. The practice of evidence‐based medicine and the acute need for more evidence on inpatient conditions require that pediatric hospitalists understand and participate in research related activities. Pediatric hospitalists' role in research will vary depending on their setting and job description. This role may include many facets, from reviewing relevant patient‐based articles, to participating in multi‐institutional studies requiring enrollment of patients, to leading local or national studies. Pediatric hospitalists need to have a basic understanding of research methods and process in order to participate in and benefit from research. This understanding contributes to the effective care of hospitalized patients.

Knowledge

Pediatric hospitalists should be able to:

• Compare and contrast different types of study design such as case‐control, cohort, observational, and randomized control trials. Understand the advantages and disadvantages of each study design.

• Name resources available to access current or proposed studies and funding sources such as the Agency for Healthcare Research and Quality (AHRQ), the National Institutes of Health (NIH), Robert Wood Johnson Foundation, clinicaltrials.gov, and others.

• Discuss what resources are required to support research components of data collection, data analysis, abstract and manuscript preparation, grant funding and others.

• Explain how results from articles published in the following formats apply to clinical practice:

   

  • Case reports and case series

  • Retrospective chart reviews

  • Secondary data analyses of large data sets

  • Randomized controlled trials

  • Meta analyses and systematic reviews

  • Practice Guidelines

  • Identify and efficiently locate the best available information resources to address questions in clinical practice, and conduct computerized scientific literature searches in a planned and systematic fashion.

  • Define basic statistical terms such as sample, discrete and continuous data variables, measures of central tendency (mean, median, and mode) and variability (variance, standard deviation, range).

  • Cite the various aspects of the research process including informed consent or assent, the role of institutional review boards (IRB), and HIPAA (Health Insurance Portability and Accountability Act).

  • Discuss special protections needed when conducting research with vulnerable populations. Define minimal risk for a healthy child and for a child with an illness.

  • List common barriers to implementation of clinical studies and describe pediatric hospitalists' role in overcoming these barriers.

   

Skills

Pediatric hospitalists should be able to:

• Demonstrate proficiency in searching the medical literature for existing relevant clinical research for their inpatients.

• Generate an answerable patient‐centered clinical question that is relevant to improving patient care.

• Apply the results of studies to clinical practice by determining whether the study subjects were similar to patients being treated, whether all clinically important outcomes were considered, identify threats to validity, and

   

  • For treatment studies, describe whether the likely benefits are worth the potential harm and cost.

  • For studies of diagnostic tests, describe whether the test is available, affordable, accurate and precise in the present clinical setting, and whether the results of the test will change the management of patients being treated.

  • For studies of harm, describe whether the magnitude of risk warrants an attempt to stop the exposure.

  • For studies of prognosis, describe whether the results of the study will lead directly to selecting therapy and/or are useful for counseling patients.

  • Provide effective informed consent or assent for patients participating in research studies as appropriate.

   

Attitudes

Pediatric hospitalists should be able to:

• Appreciate the importance of full informed consent for purposes of patient participation in clinical research.

• Appreciate the importance of patient assent, even in the presence of legal guardian informed consent, when involving children in clinical research.

• Demonstrate highly ethical principles in participating in research studies.

• Avoid conflict of interest or potential conflict of interest in participation in research studies.

• Acquire, manage, and share data collected for research purposes in a responsible and professional manner, maintaining high standards for protecting confidentiality, avoiding unjustified exclusions, sharing data, and adhering to copyright law.

Systems Organization and Improvement

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

• Encourage participation of interdisciplinary teams including nursing, social work, nutrition, pharmacy, and others in performance of research.

• Advocate for thoughtful application of research findings to improve systems of healthcare delivery.

• Support national multi‐center research efforts that improve the evidence base in inpatient pediatrics. Where appropriate, encourage participation local hospital involvement in these efforts.

• Recognize, support and promote efforts of research team members (analyst, data collector, statistician, nursing, and others).

Introduction

In 2006, the National Data Poison System captured more than 4 million calls to poison control centers in the United States, 2.4 million of which were calls regarding human exposures. More than 50% of reported toxin exposures occur in children under age 6 years. Furthermore, ingestion accounts for 75% of all toxin exposures in younger children. In this age group, toxin ingestion is frequently unintentional and involves non‐pharmacologic agents, but therapeutic errors in the administration of pharmacologic agents do occur. In adolescents, toxin ingestion is more often intentional or associated with substance abuse, and carries with it greater morbidity and mortality, particularly when pharmacological agents are involved. Pediatric hospitalists often provide immediate care, coordinate care with subspecialists, or arrange for transfer to another facility when appropriate.

Knowledge

Pediatric hospitalists should be able to:

• List the pharmacologic and non‐pharmacologic agents commonly ingested by pediatric patients and describe how the frequency of each category changes with age.

• Compare and contrast the risk factors and co‐morbidities associated with unintentional versus intentional ingestion.

• Describe the signs and symptoms of acute ingestion, including known toxidromes for commonly ingested agents such as salicylates, acetaminophen, narcotics, hallucinogens, stimulants, and others.

• Discuss the risk factors for and presentation of acute and chronic lead poisoning.

• List the laboratory tests that support or refute the diagnosis or assist with the management of common ingestions.

• List the agents detected in locally available blood and urine toxicology screens and describe the benefits and limitations of this testing.

• Explain the indications for and limitations of decontamination therapy, including dermal, ocular, and gastric decontamination methods.

• Identify toxins that have a specific antidote available and explain the indications and limitations of each.

• List local resources that provide information and advice regarding pediatric toxin ingestion management, and recognize there is a single phone number that may be used in the United States to access all regional poison center resources.

• Summarize the indications and goals of hospitalization, attending to acute and chronic medical needs and psychosocial intervention.

• Review the criteria for and process of discharge including psychiatric evaluation, inpatient psychiatric facility transfer, foster care and other elements important for safe discharge.

Skills

Pediatric hospitalists should be able to:

• Obtain a focused history, including detailed information about potential exposures, such as the type, amount, and timing of the ingestion.

• Perform a focused physical examination, with attention paid to signs and symptoms that may indicate the ingestion of a particular toxin.

• Efficiently access institutional and local resources to obtain information and advice regarding the diagnosis and management of acute ingestion.

• Identify patients presenting with common toxidromes and efficiently institute appropriate therapy.

• Recognize life‐threatening complications such as cardiac dysrhythmias, respiratory depression, or mental status change and institute appropriate therapy in a timely fashion.

• Recognize potential co‐morbidities associated with intentional ingestion, such as depression, abuse, or other mental illness.

• Correctly order and interpret basic tests, such as serum chemistries, blood gases, and electrocardiograms, and identify abnormal findings that require additional testing or consultation.

• Develop an appropriate treatment plan based on the presumptive or confirmed agent and provide decontamination or antidote therapy when appropriate.

• Determine the appropriate level of care and duration of observation for a given toxin, recognizing that some agents may have delayed toxic effects.

• Involve subspecialists when appropriate, including social work and/or psychiatric consultation for cases of non‐accidental ingestion as appropriate.

• Correctly identify patients who require legal (protective or other) involvement and efficiently access appropriate agencies.

Attitudes

Pediatric hospitalists should be able to:

• Counsel the family/caregiver and other professional staff on the possible etiology and outcomes of the ingestion episode.

• Assess the social environment to determine the risk of future exposure and the need for mitigation of risk factors prior to discharge.

• Educate caregivers regarding proactive risk reduction measures, such as the safe and effective storage, use and administration of medications.

• Realize the importance of remaining vigilant regarding changes in recreational drug availability and use as well as safety profile updates on pharmacologic and non‐pharmacologic agents.

Systems Organization and Improvement

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

• Lead, coordinate or participate in the development of systems that integrate hospital, community, and national resources to provide up‐to‐date and evidence‐based information about toxin ingestions and promote timely recognition and treatment of both intentional and unintentional ingestions.

• Lead, coordinate or participate in efforts to educate healthcare providers about the most common ingestions in the pediatric population.

• Lead, coordinate or participate in efforts to educate healthcare providers and the community, regarding ways to mitigate medication errors.

Introduction

In 2006, the National Data Poison System captured more than 4 million calls to poison control centers in the United States, 2.4 million of which were calls regarding human exposures. More than 50% of reported toxin exposures occur in children under age 6 years. Furthermore, ingestion accounts for 75% of all toxin exposures in younger children. In this age group, toxin ingestion is frequently unintentional and involves non‐pharmacologic agents, but therapeutic errors in the administration of pharmacologic agents do occur. In adolescents, toxin ingestion is more often intentional or associated with substance abuse, and carries with it greater morbidity and mortality, particularly when pharmacological agents are involved. Pediatric hospitalists often provide immediate care, coordinate care with subspecialists, or arrange for transfer to another facility when appropriate.

Knowledge

Pediatric hospitalists should be able to:

• List the pharmacologic and non‐pharmacologic agents commonly ingested by pediatric patients and describe how the frequency of each category changes with age.

• Compare and contrast the risk factors and co‐morbidities associated with unintentional versus intentional ingestion.

• Describe the signs and symptoms of acute ingestion, including known toxidromes for commonly ingested agents such as salicylates, acetaminophen, narcotics, hallucinogens, stimulants, and others.

• Discuss the risk factors for and presentation of acute and chronic lead poisoning.

• List the laboratory tests that support or refute the diagnosis or assist with the management of common ingestions.

• List the agents detected in locally available blood and urine toxicology screens and describe the benefits and limitations of this testing.

• Explain the indications for and limitations of decontamination therapy, including dermal, ocular, and gastric decontamination methods.

• Identify toxins that have a specific antidote available and explain the indications and limitations of each.

• List local resources that provide information and advice regarding pediatric toxin ingestion management, and recognize there is a single phone number that may be used in the United States to access all regional poison center resources.

• Summarize the indications and goals of hospitalization, attending to acute and chronic medical needs and psychosocial intervention.

• Review the criteria for and process of discharge including psychiatric evaluation, inpatient psychiatric facility transfer, foster care and other elements important for safe discharge.

Skills

Pediatric hospitalists should be able to:

• Obtain a focused history, including detailed information about potential exposures, such as the type, amount, and timing of the ingestion.

• Perform a focused physical examination, with attention paid to signs and symptoms that may indicate the ingestion of a particular toxin.

• Efficiently access institutional and local resources to obtain information and advice regarding the diagnosis and management of acute ingestion.

• Identify patients presenting with common toxidromes and efficiently institute appropriate therapy.

• Recognize life‐threatening complications such as cardiac dysrhythmias, respiratory depression, or mental status change and institute appropriate therapy in a timely fashion.

• Recognize potential co‐morbidities associated with intentional ingestion, such as depression, abuse, or other mental illness.

• Correctly order and interpret basic tests, such as serum chemistries, blood gases, and electrocardiograms, and identify abnormal findings that require additional testing or consultation.

• Develop an appropriate treatment plan based on the presumptive or confirmed agent and provide decontamination or antidote therapy when appropriate.

• Determine the appropriate level of care and duration of observation for a given toxin, recognizing that some agents may have delayed toxic effects.

• Involve subspecialists when appropriate, including social work and/or psychiatric consultation for cases of non‐accidental ingestion as appropriate.

• Correctly identify patients who require legal (protective or other) involvement and efficiently access appropriate agencies.

Attitudes

Pediatric hospitalists should be able to:

• Counsel the family/caregiver and other professional staff on the possible etiology and outcomes of the ingestion episode.

• Assess the social environment to determine the risk of future exposure and the need for mitigation of risk factors prior to discharge.

• Educate caregivers regarding proactive risk reduction measures, such as the safe and effective storage, use and administration of medications.

• Realize the importance of remaining vigilant regarding changes in recreational drug availability and use as well as safety profile updates on pharmacologic and non‐pharmacologic agents.

Systems Organization and Improvement

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

• Lead, coordinate or participate in the development of systems that integrate hospital, community, and national resources to provide up‐to‐date and evidence‐based information about toxin ingestions and promote timely recognition and treatment of both intentional and unintentional ingestions.

• Lead, coordinate or participate in efforts to educate healthcare providers about the most common ingestions in the pediatric population.

• Lead, coordinate or participate in efforts to educate healthcare providers and the community, regarding ways to mitigate medication errors.

Introduction

In 2006, the National Data Poison System captured more than 4 million calls to poison control centers in the United States, 2.4 million of which were calls regarding human exposures. More than 50% of reported toxin exposures occur in children under age 6 years. Furthermore, ingestion accounts for 75% of all toxin exposures in younger children. In this age group, toxin ingestion is frequently unintentional and involves non‐pharmacologic agents, but therapeutic errors in the administration of pharmacologic agents do occur. In adolescents, toxin ingestion is more often intentional or associated with substance abuse, and carries with it greater morbidity and mortality, particularly when pharmacological agents are involved. Pediatric hospitalists often provide immediate care, coordinate care with subspecialists, or arrange for transfer to another facility when appropriate.

Knowledge

Pediatric hospitalists should be able to:

• List the pharmacologic and non‐pharmacologic agents commonly ingested by pediatric patients and describe how the frequency of each category changes with age.

• Compare and contrast the risk factors and co‐morbidities associated with unintentional versus intentional ingestion.

• Describe the signs and symptoms of acute ingestion, including known toxidromes for commonly ingested agents such as salicylates, acetaminophen, narcotics, hallucinogens, stimulants, and others.

• Discuss the risk factors for and presentation of acute and chronic lead poisoning.

• List the laboratory tests that support or refute the diagnosis or assist with the management of common ingestions.

• List the agents detected in locally available blood and urine toxicology screens and describe the benefits and limitations of this testing.

• Explain the indications for and limitations of decontamination therapy, including dermal, ocular, and gastric decontamination methods.

• Identify toxins that have a specific antidote available and explain the indications and limitations of each.

• List local resources that provide information and advice regarding pediatric toxin ingestion management, and recognize there is a single phone number that may be used in the United States to access all regional poison center resources.

• Summarize the indications and goals of hospitalization, attending to acute and chronic medical needs and psychosocial intervention.

• Review the criteria for and process of discharge including psychiatric evaluation, inpatient psychiatric facility transfer, foster care and other elements important for safe discharge.

Skills

Pediatric hospitalists should be able to:

• Obtain a focused history, including detailed information about potential exposures, such as the type, amount, and timing of the ingestion.

• Perform a focused physical examination, with attention paid to signs and symptoms that may indicate the ingestion of a particular toxin.

• Efficiently access institutional and local resources to obtain information and advice regarding the diagnosis and management of acute ingestion.

• Identify patients presenting with common toxidromes and efficiently institute appropriate therapy.

• Recognize life‐threatening complications such as cardiac dysrhythmias, respiratory depression, or mental status change and institute appropriate therapy in a timely fashion.

• Recognize potential co‐morbidities associated with intentional ingestion, such as depression, abuse, or other mental illness.

• Correctly order and interpret basic tests, such as serum chemistries, blood gases, and electrocardiograms, and identify abnormal findings that require additional testing or consultation.

• Develop an appropriate treatment plan based on the presumptive or confirmed agent and provide decontamination or antidote therapy when appropriate.

• Determine the appropriate level of care and duration of observation for a given toxin, recognizing that some agents may have delayed toxic effects.

• Involve subspecialists when appropriate, including social work and/or psychiatric consultation for cases of non‐accidental ingestion as appropriate.

• Correctly identify patients who require legal (protective or other) involvement and efficiently access appropriate agencies.

Attitudes

Pediatric hospitalists should be able to:

• Counsel the family/caregiver and other professional staff on the possible etiology and outcomes of the ingestion episode.

• Assess the social environment to determine the risk of future exposure and the need for mitigation of risk factors prior to discharge.

• Educate caregivers regarding proactive risk reduction measures, such as the safe and effective storage, use and administration of medications.

• Realize the importance of remaining vigilant regarding changes in recreational drug availability and use as well as safety profile updates on pharmacologic and non‐pharmacologic agents.

Systems Organization and Improvement

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

• Lead, coordinate or participate in the development of systems that integrate hospital, community, and national resources to provide up‐to‐date and evidence‐based information about toxin ingestions and promote timely recognition and treatment of both intentional and unintentional ingestions.

• Lead, coordinate or participate in efforts to educate healthcare providers about the most common ingestions in the pediatric population.

• Lead, coordinate or participate in efforts to educate healthcare providers and the community, regarding ways to mitigate medication errors.

Introduction

Advocacy is defined as the process of speaking out in support of a specific individual, cause or program as distinct from the direct provision of material support to the individual, cause or program. In pediatric hospital medicine, advocacy can occur as an isolated event for a single patient, but is most effective when it leads to a change in an approach to a problem that supports multiple individuals in similar circumstances. Advocacy skills are part of the toolkit of both physicians and leaders. In conjunction with other healthcare professionals and organizations, pediatric hospitalists have an important role to play in advocating for both the children and the evolving field of hospital medicine. Pediatric hospitalists may also be called upon to advocate for the pediatric services or department within the hospital, as well as for children in the community.

Knowledge

Pediatric hospitalists should be able to:

• Define advocacy and health policy.

• Describe how advocacy impacts the care of children both in the hospital and the community.

• Discuss the multiple levels of advocacy, including individual, group, institutional, community, and legislative advocacy.

• Illustrate how financing of child health relates to advocacy.

• Describe the relationship between pediatric quality and advocacy.

• Discuss the various areas of focus for advocacy efforts, including disease process/diagnosis, age group, socio‐economic, cultural or demographic group, health systems, payment systems, and government or community agencies.

• Describe the legislative process and identify specific ways in which physicians can participate in this process to improve the health of children, especially those requiring hospitalization.

• List the key national organizations (such as the American Academy of Pediatrics, the Society of Hospital Medicine and National Association of Children's Hospitals and Related Institutions and others) with which pediatric hospitalists work to advocate for hospitalized pediatric patients

• Explain how private and governmental funding and oversight organizations (such as Leapfrog, Medicaid, The Joint Commission and many others) influence advocacy efforts for children's healthcare.

• Identify community characteristics, demographics, needs, and assets that impact children's healthcare, including the availability of social, educational, and medical services for children and the family/caregiver.

• State common barriers, especially those unique to the pediatric population, that impact hospital care for children.

• Cite advocacy efforts that are unique to community hospitals such as obtaining pediatric representation on key committees, establishing a relationship with a pediatric referral center, and developing relationships with adult subspecialists.

• Cite unique opportunities for advocacy in children's hospitals.

• Define the medical home and understand the role of pediatric hospitalists in delivering care within a medical home.

Skills

Pediatric hospitalists should be able to:

• Conduct effective family centered, interdisciplinary rounds.

• Consistently engage patients and the family/caregiver in medical‐decision making.

• Deliver family‐centered, comprehensive, coordinated care for medically complex children and other special populations.

• Develop collaborative relationships with other pediatric healthcare providers to advocate for children within the medical home model.

• Provide effective media interviews on relevant topics in various formats (such as print, radio, television, and other).

• Define, articulate, and gain support for the unique health care needs of children in the hospital setting as well as the community.

• Identify hospital environments or processes that lack a focus on children and take appropriate steps to advocate for pediatric‐specific needs.

• Participate in the advocacy and health policy activities sponsored by local, community, and national organizations.

Attitudes

Pediatric hospitalists should be able to:

• Accept responsibility for child health advocacy.

• Recognize the cultural beliefs and biases of patients, family/caregiver, and healthcare providers and adapt to advocate for patients' needs.

• Realize that the most effective advocacy involves creation of coalitions and teams.

• Maintain awareness of political, cultural, and socio‐economic factors affecting children's healthcare and the practice of pediatric hospital medicine.

Systems Organization and Improvement

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

• Incorporate the institution's mission and vision statements into daily work.

• Work with key hospital leaders to assure child advocacy is fully integrated into the delivery of care on a daily basis.

• Establish effective relationships with hospital leaders, community leaders and local politicians to target a specific issue and/or serve as an expert pediatric consultant.

• Participate in the development of systems of care in your institution and beyond that promote effective care for hospitalized children.

Introduction

Advocacy is defined as the process of speaking out in support of a specific individual, cause or program as distinct from the direct provision of material support to the individual, cause or program. In pediatric hospital medicine, advocacy can occur as an isolated event for a single patient, but is most effective when it leads to a change in an approach to a problem that supports multiple individuals in similar circumstances. Advocacy skills are part of the toolkit of both physicians and leaders. In conjunction with other healthcare professionals and organizations, pediatric hospitalists have an important role to play in advocating for both the children and the evolving field of hospital medicine. Pediatric hospitalists may also be called upon to advocate for the pediatric services or department within the hospital, as well as for children in the community.

Knowledge

Pediatric hospitalists should be able to:

• Define advocacy and health policy.

• Describe how advocacy impacts the care of children both in the hospital and the community.

• Discuss the multiple levels of advocacy, including individual, group, institutional, community, and legislative advocacy.

• Illustrate how financing of child health relates to advocacy.

• Describe the relationship between pediatric quality and advocacy.

• Discuss the various areas of focus for advocacy efforts, including disease process/diagnosis, age group, socio‐economic, cultural or demographic group, health systems, payment systems, and government or community agencies.

• Describe the legislative process and identify specific ways in which physicians can participate in this process to improve the health of children, especially those requiring hospitalization.

• List the key national organizations (such as the American Academy of Pediatrics, the Society of Hospital Medicine and National Association of Children's Hospitals and Related Institutions and others) with which pediatric hospitalists work to advocate for hospitalized pediatric patients

• Explain how private and governmental funding and oversight organizations (such as Leapfrog, Medicaid, The Joint Commission and many others) influence advocacy efforts for children's healthcare.

• Identify community characteristics, demographics, needs, and assets that impact children's healthcare, including the availability of social, educational, and medical services for children and the family/caregiver.

• State common barriers, especially those unique to the pediatric population, that impact hospital care for children.

• Cite advocacy efforts that are unique to community hospitals such as obtaining pediatric representation on key committees, establishing a relationship with a pediatric referral center, and developing relationships with adult subspecialists.

• Cite unique opportunities for advocacy in children's hospitals.

• Define the medical home and understand the role of pediatric hospitalists in delivering care within a medical home.

Skills

Pediatric hospitalists should be able to:

• Conduct effective family centered, interdisciplinary rounds.

• Consistently engage patients and the family/caregiver in medical‐decision making.

• Deliver family‐centered, comprehensive, coordinated care for medically complex children and other special populations.

• Develop collaborative relationships with other pediatric healthcare providers to advocate for children within the medical home model.

• Provide effective media interviews on relevant topics in various formats (such as print, radio, television, and other).

• Define, articulate, and gain support for the unique health care needs of children in the hospital setting as well as the community.

• Identify hospital environments or processes that lack a focus on children and take appropriate steps to advocate for pediatric‐specific needs.

• Participate in the advocacy and health policy activities sponsored by local, community, and national organizations.

Attitudes

Pediatric hospitalists should be able to:

• Accept responsibility for child health advocacy.

• Recognize the cultural beliefs and biases of patients, family/caregiver, and healthcare providers and adapt to advocate for patients' needs.

• Realize that the most effective advocacy involves creation of coalitions and teams.

• Maintain awareness of political, cultural, and socio‐economic factors affecting children's healthcare and the practice of pediatric hospital medicine.

Systems Organization and Improvement

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

• Incorporate the institution's mission and vision statements into daily work.

• Work with key hospital leaders to assure child advocacy is fully integrated into the delivery of care on a daily basis.

• Establish effective relationships with hospital leaders, community leaders and local politicians to target a specific issue and/or serve as an expert pediatric consultant.

• Participate in the development of systems of care in your institution and beyond that promote effective care for hospitalized children.

Introduction

Advocacy is defined as the process of speaking out in support of a specific individual, cause or program as distinct from the direct provision of material support to the individual, cause or program. In pediatric hospital medicine, advocacy can occur as an isolated event for a single patient, but is most effective when it leads to a change in an approach to a problem that supports multiple individuals in similar circumstances. Advocacy skills are part of the toolkit of both physicians and leaders. In conjunction with other healthcare professionals and organizations, pediatric hospitalists have an important role to play in advocating for both the children and the evolving field of hospital medicine. Pediatric hospitalists may also be called upon to advocate for the pediatric services or department within the hospital, as well as for children in the community.

Knowledge

Pediatric hospitalists should be able to:

• Define advocacy and health policy.

• Describe how advocacy impacts the care of children both in the hospital and the community.

• Discuss the multiple levels of advocacy, including individual, group, institutional, community, and legislative advocacy.

• Illustrate how financing of child health relates to advocacy.

• Describe the relationship between pediatric quality and advocacy.

• Discuss the various areas of focus for advocacy efforts, including disease process/diagnosis, age group, socio‐economic, cultural or demographic group, health systems, payment systems, and government or community agencies.

• Describe the legislative process and identify specific ways in which physicians can participate in this process to improve the health of children, especially those requiring hospitalization.

• List the key national organizations (such as the American Academy of Pediatrics, the Society of Hospital Medicine and National Association of Children's Hospitals and Related Institutions and others) with which pediatric hospitalists work to advocate for hospitalized pediatric patients

• Explain how private and governmental funding and oversight organizations (such as Leapfrog, Medicaid, The Joint Commission and many others) influence advocacy efforts for children's healthcare.

• Identify community characteristics, demographics, needs, and assets that impact children's healthcare, including the availability of social, educational, and medical services for children and the family/caregiver.

• State common barriers, especially those unique to the pediatric population, that impact hospital care for children.

• Cite advocacy efforts that are unique to community hospitals such as obtaining pediatric representation on key committees, establishing a relationship with a pediatric referral center, and developing relationships with adult subspecialists.

• Cite unique opportunities for advocacy in children's hospitals.

• Define the medical home and understand the role of pediatric hospitalists in delivering care within a medical home.

Skills

Pediatric hospitalists should be able to:

• Conduct effective family centered, interdisciplinary rounds.

• Consistently engage patients and the family/caregiver in medical‐decision making.

• Deliver family‐centered, comprehensive, coordinated care for medically complex children and other special populations.

• Develop collaborative relationships with other pediatric healthcare providers to advocate for children within the medical home model.

• Provide effective media interviews on relevant topics in various formats (such as print, radio, television, and other).

• Define, articulate, and gain support for the unique health care needs of children in the hospital setting as well as the community.

• Identify hospital environments or processes that lack a focus on children and take appropriate steps to advocate for pediatric‐specific needs.

• Participate in the advocacy and health policy activities sponsored by local, community, and national organizations.

Attitudes

Pediatric hospitalists should be able to:

• Accept responsibility for child health advocacy.

• Recognize the cultural beliefs and biases of patients, family/caregiver, and healthcare providers and adapt to advocate for patients' needs.

• Realize that the most effective advocacy involves creation of coalitions and teams.

• Maintain awareness of political, cultural, and socio‐economic factors affecting children's healthcare and the practice of pediatric hospital medicine.

Systems Organization and Improvement

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

• Incorporate the institution's mission and vision statements into daily work.

• Work with key hospital leaders to assure child advocacy is fully integrated into the delivery of care on a daily basis.

• Establish effective relationships with hospital leaders, community leaders and local politicians to target a specific issue and/or serve as an expert pediatric consultant.

• Participate in the development of systems of care in your institution and beyond that promote effective care for hospitalized children.

Introduction

Seizures are the most common neurologic disorder of childhood. It is estimated that approximately 5% of all children will have at least one seizure before the age of 20. The prevalence of epilepsy, or recurrent unprovoked seizures, is about 0.5% in children. Seizures may range from self‐limited to life‐threatening events. Status epilepticus is the condition of prolonged seizure activity. Optimal management of seizures not only includes identification of the underlying cause and initiation of appropriate anticonvulsant therapy or other treatments, but also the maintenance and management of an adequate airway and circulation. Pediatric hospitalists frequently encounter patients with active seizures and underlying seizure disorders, and should render both acute care and coordination of multidisciplinary care to the ambulatory setting.

Knowledge

Pediatric hospitalists should be able to:

• Describe and distinguish between the various manifestations of seizure activity including involuntary motor activity, alterations of consciousness, behavior changes, disturbances of sensation and autonomic dysfunction.

• Classify seizures using appropriate descriptive terms such as generalized, partial, simple and complex.

• Discuss the pathophysiology of seizure activity.

• Review alternate diagnoses which may mimic the presentation of seizures including behavioral abnormalities, movement disorders, conversion disorders and others.

• Compare and contrast distinguishing features of seizures versus other paroxysmal events.

• List the various etiologies of seizures attending to both acute (such as electrolyte imbalance, infection, toxins, trauma and others) and chronic (such as central nervous system malformations, metabolic diseases, and others) causes.

• List the most common etiologies of seizures in various age groups such as the neonate, infant, preschool aged, school aged, and adolescent.

• Define simple and complex febrile seizures and discuss evaluation, treatment, prognosis, and indications for admission.

• State the common complications associated with seizures and status epilepticus.

• Discuss indications for hospitalization or transfer to a tertiary care facility.

• Discuss indications for transfer to an intensive care unit.

• Review the goals of inpatient diagnostic evaluation and therapy.

• Compare and contrast commonly used anti‐epileptic drugs and therapies attending to treatments for specific seizure types, adverse drug events, and ease of use.

• Compare and contrast the risk and benefits of commonly used imaging modalities.

• List the indications for subspecialty consultation.

• Review the management of status epilepticus, including stabilization, testing, monitoring, and patient placement.

• Summarize the risks for readmission, attending to medication management (dosing, availability, pharmacokinetics, and side effect profiles), compliance, and changes in disease state.

Skills

Pediatric hospitalists should be able to:

• Correctly diagnose seizures by efficiently performing an accurate history and physical examination with particular focus on the neurologic exam.

• Accurately order appropriate laboratory and radiographic evaluations to identify the etiology of the seizure and potential underlying disorders.

• Interpret laboratory studies including drug levels and make therapy adjustments based on results.

• Order appropriate studies for patients with chronic seizure disorders, avoiding unnecessary duplication of testing and radiation exposure.

• Identify and efficiently treat the cause of the seizure where appropriate.

• Identify status epilepticus and initiate appropriate evidence‐based treatment.

• Recognize complications due to seizures and institute appropriate cardiorespiratory support as needed.

• Identify patients at increased risk for seizure recurrence or morbidity and ensures appropriate monitoring and treatment.

• Obtain appropriate consults efficiently.

• Create a comprehensive evaluation and management plan addressing the unique needs of patients and the family/caregiver.

• Anticipate, monitor for, identify, and treat potential side effects of treatment.

• Recognize and efficiently transfer patients requiring higher level of care.

Attitudes

Pediatric hospitalists should be able to:

• Communicate effectively with patients, the family/caregiver, hospital staff, subspecialists and primary care provider regarding the reasons for diagnostic testing and therapy choices.

• Recognize the role of patient and family/caregiver education in improving compliance with treatment and follow‐up.

• Educate the family/caregiver regarding outcomes of febrile seizures including the risk of the child developing a seizure disorder.

• Collaborate with subspecialists and the primary care provider to ensure coordinated longitudinal care for children with seizure disorders.

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 of hospitalized children with seizures and status epilepticus.

• Collaborate with hospital administration and community partners to develop and sustain referral networks for both transport and subpsecialty services for children with seizures and chronic seizure disorders.

• Collaborate with primary care providers, subspecialists and other healthcare providers to create effective discharge plans that reduce the likelihood of readmission.

Introduction

Seizures are the most common neurologic disorder of childhood. It is estimated that approximately 5% of all children will have at least one seizure before the age of 20. The prevalence of epilepsy, or recurrent unprovoked seizures, is about 0.5% in children. Seizures may range from self‐limited to life‐threatening events. Status epilepticus is the condition of prolonged seizure activity. Optimal management of seizures not only includes identification of the underlying cause and initiation of appropriate anticonvulsant therapy or other treatments, but also the maintenance and management of an adequate airway and circulation. Pediatric hospitalists frequently encounter patients with active seizures and underlying seizure disorders, and should render both acute care and coordination of multidisciplinary care to the ambulatory setting.

Knowledge

Pediatric hospitalists should be able to:

• Describe and distinguish between the various manifestations of seizure activity including involuntary motor activity, alterations of consciousness, behavior changes, disturbances of sensation and autonomic dysfunction.

• Classify seizures using appropriate descriptive terms such as generalized, partial, simple and complex.

• Discuss the pathophysiology of seizure activity.

• Review alternate diagnoses which may mimic the presentation of seizures including behavioral abnormalities, movement disorders, conversion disorders and others.

• Compare and contrast distinguishing features of seizures versus other paroxysmal events.

• List the various etiologies of seizures attending to both acute (such as electrolyte imbalance, infection, toxins, trauma and others) and chronic (such as central nervous system malformations, metabolic diseases, and others) causes.

• List the most common etiologies of seizures in various age groups such as the neonate, infant, preschool aged, school aged, and adolescent.

• Define simple and complex febrile seizures and discuss evaluation, treatment, prognosis, and indications for admission.

• State the common complications associated with seizures and status epilepticus.

• Discuss indications for hospitalization or transfer to a tertiary care facility.

• Discuss indications for transfer to an intensive care unit.

• Review the goals of inpatient diagnostic evaluation and therapy.

• Compare and contrast commonly used anti‐epileptic drugs and therapies attending to treatments for specific seizure types, adverse drug events, and ease of use.

• Compare and contrast the risk and benefits of commonly used imaging modalities.

• List the indications for subspecialty consultation.

• Review the management of status epilepticus, including stabilization, testing, monitoring, and patient placement.

• Summarize the risks for readmission, attending to medication management (dosing, availability, pharmacokinetics, and side effect profiles), compliance, and changes in disease state.

Skills

Pediatric hospitalists should be able to:

• Correctly diagnose seizures by efficiently performing an accurate history and physical examination with particular focus on the neurologic exam.

• Accurately order appropriate laboratory and radiographic evaluations to identify the etiology of the seizure and potential underlying disorders.

• Interpret laboratory studies including drug levels and make therapy adjustments based on results.

• Order appropriate studies for patients with chronic seizure disorders, avoiding unnecessary duplication of testing and radiation exposure.

• Identify and efficiently treat the cause of the seizure where appropriate.

• Identify status epilepticus and initiate appropriate evidence‐based treatment.

• Recognize complications due to seizures and institute appropriate cardiorespiratory support as needed.

• Identify patients at increased risk for seizure recurrence or morbidity and ensures appropriate monitoring and treatment.

• Obtain appropriate consults efficiently.

• Create a comprehensive evaluation and management plan addressing the unique needs of patients and the family/caregiver.

• Anticipate, monitor for, identify, and treat potential side effects of treatment.

• Recognize and efficiently transfer patients requiring higher level of care.

Attitudes

Pediatric hospitalists should be able to:

• Communicate effectively with patients, the family/caregiver, hospital staff, subspecialists and primary care provider regarding the reasons for diagnostic testing and therapy choices.

• Recognize the role of patient and family/caregiver education in improving compliance with treatment and follow‐up.

• Educate the family/caregiver regarding outcomes of febrile seizures including the risk of the child developing a seizure disorder.

• Collaborate with subspecialists and the primary care provider to ensure coordinated longitudinal care for children with seizure disorders.

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 of hospitalized children with seizures and status epilepticus.

• Collaborate with hospital administration and community partners to develop and sustain referral networks for both transport and subpsecialty services for children with seizures and chronic seizure disorders.

• Collaborate with primary care providers, subspecialists and other healthcare providers to create effective discharge plans that reduce the likelihood of readmission.

Introduction

Seizures are the most common neurologic disorder of childhood. It is estimated that approximately 5% of all children will have at least one seizure before the age of 20. The prevalence of epilepsy, or recurrent unprovoked seizures, is about 0.5% in children. Seizures may range from self‐limited to life‐threatening events. Status epilepticus is the condition of prolonged seizure activity. Optimal management of seizures not only includes identification of the underlying cause and initiation of appropriate anticonvulsant therapy or other treatments, but also the maintenance and management of an adequate airway and circulation. Pediatric hospitalists frequently encounter patients with active seizures and underlying seizure disorders, and should render both acute care and coordination of multidisciplinary care to the ambulatory setting.

Knowledge

Pediatric hospitalists should be able to:

• Describe and distinguish between the various manifestations of seizure activity including involuntary motor activity, alterations of consciousness, behavior changes, disturbances of sensation and autonomic dysfunction.

• Classify seizures using appropriate descriptive terms such as generalized, partial, simple and complex.

• Discuss the pathophysiology of seizure activity.

• Review alternate diagnoses which may mimic the presentation of seizures including behavioral abnormalities, movement disorders, conversion disorders and others.

• Compare and contrast distinguishing features of seizures versus other paroxysmal events.

• List the various etiologies of seizures attending to both acute (such as electrolyte imbalance, infection, toxins, trauma and others) and chronic (such as central nervous system malformations, metabolic diseases, and others) causes.

• List the most common etiologies of seizures in various age groups such as the neonate, infant, preschool aged, school aged, and adolescent.

• Define simple and complex febrile seizures and discuss evaluation, treatment, prognosis, and indications for admission.

• State the common complications associated with seizures and status epilepticus.

• Discuss indications for hospitalization or transfer to a tertiary care facility.

• Discuss indications for transfer to an intensive care unit.

• Review the goals of inpatient diagnostic evaluation and therapy.

• Compare and contrast commonly used anti‐epileptic drugs and therapies attending to treatments for specific seizure types, adverse drug events, and ease of use.

• Compare and contrast the risk and benefits of commonly used imaging modalities.

• List the indications for subspecialty consultation.

• Review the management of status epilepticus, including stabilization, testing, monitoring, and patient placement.

• Summarize the risks for readmission, attending to medication management (dosing, availability, pharmacokinetics, and side effect profiles), compliance, and changes in disease state.

Skills

Pediatric hospitalists should be able to:

• Correctly diagnose seizures by efficiently performing an accurate history and physical examination with particular focus on the neurologic exam.

• Accurately order appropriate laboratory and radiographic evaluations to identify the etiology of the seizure and potential underlying disorders.

• Interpret laboratory studies including drug levels and make therapy adjustments based on results.

• Order appropriate studies for patients with chronic seizure disorders, avoiding unnecessary duplication of testing and radiation exposure.

• Identify and efficiently treat the cause of the seizure where appropriate.

• Identify status epilepticus and initiate appropriate evidence‐based treatment.

• Recognize complications due to seizures and institute appropriate cardiorespiratory support as needed.

• Identify patients at increased risk for seizure recurrence or morbidity and ensures appropriate monitoring and treatment.

• Obtain appropriate consults efficiently.

• Create a comprehensive evaluation and management plan addressing the unique needs of patients and the family/caregiver.

• Anticipate, monitor for, identify, and treat potential side effects of treatment.

• Recognize and efficiently transfer patients requiring higher level of care.

Attitudes

Pediatric hospitalists should be able to:

• Communicate effectively with patients, the family/caregiver, hospital staff, subspecialists and primary care provider regarding the reasons for diagnostic testing and therapy choices.

• Recognize the role of patient and family/caregiver education in improving compliance with treatment and follow‐up.

• Educate the family/caregiver regarding outcomes of febrile seizures including the risk of the child developing a seizure disorder.

• Collaborate with subspecialists and the primary care provider to ensure coordinated longitudinal care for children with seizure disorders.

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 of hospitalized children with seizures and status epilepticus.

• Collaborate with hospital administration and community partners to develop and sustain referral networks for both transport and subpsecialty services for children with seizures and chronic seizure disorders.

• Collaborate with primary care providers, subspecialists and other healthcare providers to create effective discharge plans that reduce the likelihood of readmission.