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Bronchiolitis
Introduction
Bronchiolitis is the most common viral lower respiratory illness in young children and infants. It is responsible for hundreds of thousands of outpatient and emergency department visits and nearly 150,000 hospitalizations per year, costing the U.S. healthcare system more than $500 million annually. The most commonly identified etiology of bronchiolitis is respiratory syncytial virus (RSV), however bronchiolitis may be caused by many other viruses, including human metapneumovirus, adenovirus, and influenza. Despite guidelines published by the American Academy of Pediatrics on the diagnosis and management of bronchiolitis, there is significant variation in care of hospitalized patients. Pediatric hospitalists should render evidence‐based care that avoids use of unnecessary tests and procedures and improves outcomes.
Knowledge
Pediatric hospitalists should be able to:
Compare and contrast the epidemiology and pathogenesis of bronchiolitis with asthma.
Describe the typical clinical presentation of viral bronchiolitis including wheezing, tachypnea, acute respiratory distress, hypoxia, cough, apnea, and/or nasal obstruction, and give examples of how presentations may vary.
Review alternate diagnoses which may mimic the presentation of bronchiolitis such as congestive heart failure, previously undiagnosed cyanotic or non‐cyanotic congenital heart disease, metabolic acidosis, sepsis, aspiration, and others.
Identify the risk factors such as prematurity, congenital heart disease, pulmonary disease, immunodeficiency, and environmental smoke exposure that predispose infants and children to severe illness or complications of bronchiolitis.
State the indications and contraindications for RSV immunoprophylaxis.
List the indications for hospital admission and cite discharge criteria.
Discuss indications for ordering viral antigen testing and chest radiographs.
Compare and contrast initial diagnostic evaluation for febrile infants of various ages presenting with bronchiolitis attending to ages less than 30 days, 31‐60 days and others.
Discuss the evidence regarding beta‐agonist and steroid therapy in routine bronchiolitis.
Discuss the evidence regarding use of supportive measures including suctioning, positioning, enteral versus intravenous fluids and nutrition, and supplemental oxygen.
Discuss the benefits and potential technical errors associated with use of various non‐invasive monitoring modalities including cardiorespiratory, oxygen saturation, and capnography.
Describe a management strategy for patients with worsening respiratory status including the use of different oxygen delivery systems and methods for positive pressure ventilation.
Describe a management strategy for patients with worsening respiratory status including use of different oxygen delivery systems and methods for positive pressure ventilation.
Skills
Pediatric hospitalists should be able to:
Correctly diagnose bronchiolitis by efficiently performing an accurate history and physical examination; determining if key features of the disease are present.
Accurately assess clinical signs of respiratory distress and identify impending respiratory failure.
Assess nutrition and hydration status and chose appropriate methods to maintain adequate hydration and nutrition.
Order appropriate monitoring and correctly interpret monitor data.
Objectively assess the response to any medications trialed and use clinical exam and respiratory scores to determine true efficacy.
Perform careful reassessments daily and as needed, note changes in clinical status and respond with appropriate actions including discontinuation of ineffective or unnecessary therapies.
Recognize the indications for escalating level of care and initiate basic ventilatory support if indicated.
Implement appropriate oxygen weaning strategies, including the use of appropriate oxygen saturation parameters.
Engage the family/caregiver in assisting with interpreting clinical status changes and in determining care plans.
Consistently adhere to proper infection control measures.
Efficiently render care by creating a discharge plan which can be expediently activated when appropriate.
Attitudes
Pediatric hospitalists should be able to:
Educate the family/caregiver on the etiologies and natural history of bronchiolitis, including the importance of hand washing and minimizing environmental exposure in the prevention of infection.
Discuss with the family/caregiver the importance of supportive care, as well as the limited evidence supporting other interventions.
Display proactive, engaged behavior regarding proper isolation measures particularly including hand‐washing to prevent spread of the etiologic agent in the hospital.
Educate the family/caregiver regarding the relationship between hospitalization for bronchiolitis and risk of future wheezing based on the most current evidence.
Collaborate with the primary care provider to ensure a smooth transition to the outpatient setting, and to minimize the need for readmission.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Collaborate with hospital infection control practitioners to prevent nosocomial infection related to bronchiolitis.
Partner with community services to educate the public on respiratory infection preventive strategies.
Work with emergency department physicians to mutually develop and implement evidence‐based admission criteria.
Lead, coordinate or participate in multidisciplinary initiatives to develop, implement, and assess quality outcomes of evidence‐based clinical guidelines.
Introduction
Bronchiolitis is the most common viral lower respiratory illness in young children and infants. It is responsible for hundreds of thousands of outpatient and emergency department visits and nearly 150,000 hospitalizations per year, costing the U.S. healthcare system more than $500 million annually. The most commonly identified etiology of bronchiolitis is respiratory syncytial virus (RSV), however bronchiolitis may be caused by many other viruses, including human metapneumovirus, adenovirus, and influenza. Despite guidelines published by the American Academy of Pediatrics on the diagnosis and management of bronchiolitis, there is significant variation in care of hospitalized patients. Pediatric hospitalists should render evidence‐based care that avoids use of unnecessary tests and procedures and improves outcomes.
Knowledge
Pediatric hospitalists should be able to:
Compare and contrast the epidemiology and pathogenesis of bronchiolitis with asthma.
Describe the typical clinical presentation of viral bronchiolitis including wheezing, tachypnea, acute respiratory distress, hypoxia, cough, apnea, and/or nasal obstruction, and give examples of how presentations may vary.
Review alternate diagnoses which may mimic the presentation of bronchiolitis such as congestive heart failure, previously undiagnosed cyanotic or non‐cyanotic congenital heart disease, metabolic acidosis, sepsis, aspiration, and others.
Identify the risk factors such as prematurity, congenital heart disease, pulmonary disease, immunodeficiency, and environmental smoke exposure that predispose infants and children to severe illness or complications of bronchiolitis.
State the indications and contraindications for RSV immunoprophylaxis.
List the indications for hospital admission and cite discharge criteria.
Discuss indications for ordering viral antigen testing and chest radiographs.
Compare and contrast initial diagnostic evaluation for febrile infants of various ages presenting with bronchiolitis attending to ages less than 30 days, 31‐60 days and others.
Discuss the evidence regarding beta‐agonist and steroid therapy in routine bronchiolitis.
Discuss the evidence regarding use of supportive measures including suctioning, positioning, enteral versus intravenous fluids and nutrition, and supplemental oxygen.
Discuss the benefits and potential technical errors associated with use of various non‐invasive monitoring modalities including cardiorespiratory, oxygen saturation, and capnography.
Describe a management strategy for patients with worsening respiratory status including the use of different oxygen delivery systems and methods for positive pressure ventilation.
Describe a management strategy for patients with worsening respiratory status including use of different oxygen delivery systems and methods for positive pressure ventilation.
Skills
Pediatric hospitalists should be able to:
Correctly diagnose bronchiolitis by efficiently performing an accurate history and physical examination; determining if key features of the disease are present.
Accurately assess clinical signs of respiratory distress and identify impending respiratory failure.
Assess nutrition and hydration status and chose appropriate methods to maintain adequate hydration and nutrition.
Order appropriate monitoring and correctly interpret monitor data.
Objectively assess the response to any medications trialed and use clinical exam and respiratory scores to determine true efficacy.
Perform careful reassessments daily and as needed, note changes in clinical status and respond with appropriate actions including discontinuation of ineffective or unnecessary therapies.
Recognize the indications for escalating level of care and initiate basic ventilatory support if indicated.
Implement appropriate oxygen weaning strategies, including the use of appropriate oxygen saturation parameters.
Engage the family/caregiver in assisting with interpreting clinical status changes and in determining care plans.
Consistently adhere to proper infection control measures.
Efficiently render care by creating a discharge plan which can be expediently activated when appropriate.
Attitudes
Pediatric hospitalists should be able to:
Educate the family/caregiver on the etiologies and natural history of bronchiolitis, including the importance of hand washing and minimizing environmental exposure in the prevention of infection.
Discuss with the family/caregiver the importance of supportive care, as well as the limited evidence supporting other interventions.
Display proactive, engaged behavior regarding proper isolation measures particularly including hand‐washing to prevent spread of the etiologic agent in the hospital.
Educate the family/caregiver regarding the relationship between hospitalization for bronchiolitis and risk of future wheezing based on the most current evidence.
Collaborate with the primary care provider to ensure a smooth transition to the outpatient setting, and to minimize the need for readmission.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Collaborate with hospital infection control practitioners to prevent nosocomial infection related to bronchiolitis.
Partner with community services to educate the public on respiratory infection preventive strategies.
Work with emergency department physicians to mutually develop and implement evidence‐based admission criteria.
Lead, coordinate or participate in multidisciplinary initiatives to develop, implement, and assess quality outcomes of evidence‐based clinical guidelines.
Introduction
Bronchiolitis is the most common viral lower respiratory illness in young children and infants. It is responsible for hundreds of thousands of outpatient and emergency department visits and nearly 150,000 hospitalizations per year, costing the U.S. healthcare system more than $500 million annually. The most commonly identified etiology of bronchiolitis is respiratory syncytial virus (RSV), however bronchiolitis may be caused by many other viruses, including human metapneumovirus, adenovirus, and influenza. Despite guidelines published by the American Academy of Pediatrics on the diagnosis and management of bronchiolitis, there is significant variation in care of hospitalized patients. Pediatric hospitalists should render evidence‐based care that avoids use of unnecessary tests and procedures and improves outcomes.
Knowledge
Pediatric hospitalists should be able to:
Compare and contrast the epidemiology and pathogenesis of bronchiolitis with asthma.
Describe the typical clinical presentation of viral bronchiolitis including wheezing, tachypnea, acute respiratory distress, hypoxia, cough, apnea, and/or nasal obstruction, and give examples of how presentations may vary.
Review alternate diagnoses which may mimic the presentation of bronchiolitis such as congestive heart failure, previously undiagnosed cyanotic or non‐cyanotic congenital heart disease, metabolic acidosis, sepsis, aspiration, and others.
Identify the risk factors such as prematurity, congenital heart disease, pulmonary disease, immunodeficiency, and environmental smoke exposure that predispose infants and children to severe illness or complications of bronchiolitis.
State the indications and contraindications for RSV immunoprophylaxis.
List the indications for hospital admission and cite discharge criteria.
Discuss indications for ordering viral antigen testing and chest radiographs.
Compare and contrast initial diagnostic evaluation for febrile infants of various ages presenting with bronchiolitis attending to ages less than 30 days, 31‐60 days and others.
Discuss the evidence regarding beta‐agonist and steroid therapy in routine bronchiolitis.
Discuss the evidence regarding use of supportive measures including suctioning, positioning, enteral versus intravenous fluids and nutrition, and supplemental oxygen.
Discuss the benefits and potential technical errors associated with use of various non‐invasive monitoring modalities including cardiorespiratory, oxygen saturation, and capnography.
Describe a management strategy for patients with worsening respiratory status including the use of different oxygen delivery systems and methods for positive pressure ventilation.
Describe a management strategy for patients with worsening respiratory status including use of different oxygen delivery systems and methods for positive pressure ventilation.
Skills
Pediatric hospitalists should be able to:
Correctly diagnose bronchiolitis by efficiently performing an accurate history and physical examination; determining if key features of the disease are present.
Accurately assess clinical signs of respiratory distress and identify impending respiratory failure.
Assess nutrition and hydration status and chose appropriate methods to maintain adequate hydration and nutrition.
Order appropriate monitoring and correctly interpret monitor data.
Objectively assess the response to any medications trialed and use clinical exam and respiratory scores to determine true efficacy.
Perform careful reassessments daily and as needed, note changes in clinical status and respond with appropriate actions including discontinuation of ineffective or unnecessary therapies.
Recognize the indications for escalating level of care and initiate basic ventilatory support if indicated.
Implement appropriate oxygen weaning strategies, including the use of appropriate oxygen saturation parameters.
Engage the family/caregiver in assisting with interpreting clinical status changes and in determining care plans.
Consistently adhere to proper infection control measures.
Efficiently render care by creating a discharge plan which can be expediently activated when appropriate.
Attitudes
Pediatric hospitalists should be able to:
Educate the family/caregiver on the etiologies and natural history of bronchiolitis, including the importance of hand washing and minimizing environmental exposure in the prevention of infection.
Discuss with the family/caregiver the importance of supportive care, as well as the limited evidence supporting other interventions.
Display proactive, engaged behavior regarding proper isolation measures particularly including hand‐washing to prevent spread of the etiologic agent in the hospital.
Educate the family/caregiver regarding the relationship between hospitalization for bronchiolitis and risk of future wheezing based on the most current evidence.
Collaborate with the primary care provider to ensure a smooth transition to the outpatient setting, and to minimize the need for readmission.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Collaborate with hospital infection control practitioners to prevent nosocomial infection related to bronchiolitis.
Partner with community services to educate the public on respiratory infection preventive strategies.
Work with emergency department physicians to mutually develop and implement evidence‐based admission criteria.
Lead, coordinate or participate in multidisciplinary initiatives to develop, implement, and assess quality outcomes of evidence‐based clinical guidelines.
Copyright © 2010 Society of Hospital Medicine
Radiographic interpretation
Introduction
Radiographic studies are commonly performed throughout a wide range of pediatric healthcare settings. Imaging can play a pivotal role in the acute and chronic medical and surgical management of ill children. The explosion of imaging technology and expertise in the past three decades has resulted in an increased array of imaging modalities from which to choose. Access to and interpretation of imaging studies for children varies greatly between facilities. Pediatric hospitalists frequently encounter patients requiring imaging studies, and should be adept at ordering and interpreting images in collaboration with radiologist and other subspecialists.
Knowledge
Pediatric hospitalists should be able to:
Review basic human anatomy and relate this to interpretation of common plain radiographs of areas such as the chest, abdomen, airway, and long bones.
Describe the indications and limitations of the common radiographic modalities such as sonography, computed tomography, magnetic resonance imaging, plain radiography, and bone scans.
Describe the risks of ionizing radiation in children and review the concept of ALARA (as low as reasonably achievable) in limiting radiation exposure.
Review the indications for and benefits and risks of oral and intravenous contrast.
Review the indications for anxiolysis, sedation, and anaesthesia attending to age, developmental stage, and procedure being performed.
Compare and contrast indications for interventional radiologist versus general surgical consultation.
Discuss the role of the radiologist as consultant.
Discuss the appropriate imaging modality selection(s) for common emergent clinical presentations such as altered mental status, stridor, potential bowel obstruction, and others.
Compare and contrast the utility, risks, and costs of different imaging modalities for presentations of complicated pneumonia and acute abdominal pain.
Skills
Pediatric hospitalists should be able to:
Correctly determine the optimal study to answer a specific clinical question in a cost‐effective manner, accounting for the limitations and risks of the study.
Accurately order radiologic studies, noting indications for the study, sedation/anaesthesia need, and other relevant information in the order.
Engage the radiologist as consultant as appropriate.
Accurately interpret plain radiographs of the chest and abdomen for children 0‐18 years of age.
Correctly identify the need for and efficiently access interventional radiologists as appropriate.
Communicate effectively with the healthcare team including radiologist and anaesthesiologist (as appropriate) to ensure safe, efficient and effective performance of radiologic studies.
Correctly interpret and apply the results of radiographic studies into clinical care plans.
Attitudes
Pediatric hospitalists should be able to:
Elicit and allay common family/caregiver concerns regarding radiation risks.
Work collaboratively with hospital staff, radiologists, and anaesthesiologists to ensure coordinated planning and performance of radiologic studies.
Communicate effectively with patients and the family/caregiver regarding the indications for, risks, benefits, and steps involved in the radiologic procedure.
Recognize the importance of obtaining results of all studies and reviewing images in person whenever possible.
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 standards for radiology services for children.
Work with hospital administration to assure that a reliable and efficient radiographic imaging service is available for pediatric inpatients at the local facility.
Lead, coordinate or participate in development and implementation of a system to review the accuracy of readings for pediatric patients and develop local criteria for tertiary referral center consultation.
Collaborate with hospital administration and community partners to develop and sustain referral networks between local facilities and tertiary referral centers that enable review of appropriately selected pediatric images.
Work with hospital administration, subspecialists, and others to review acquisition of new technologies and assess the impact on patient care.
Introduction
Radiographic studies are commonly performed throughout a wide range of pediatric healthcare settings. Imaging can play a pivotal role in the acute and chronic medical and surgical management of ill children. The explosion of imaging technology and expertise in the past three decades has resulted in an increased array of imaging modalities from which to choose. Access to and interpretation of imaging studies for children varies greatly between facilities. Pediatric hospitalists frequently encounter patients requiring imaging studies, and should be adept at ordering and interpreting images in collaboration with radiologist and other subspecialists.
Knowledge
Pediatric hospitalists should be able to:
Review basic human anatomy and relate this to interpretation of common plain radiographs of areas such as the chest, abdomen, airway, and long bones.
Describe the indications and limitations of the common radiographic modalities such as sonography, computed tomography, magnetic resonance imaging, plain radiography, and bone scans.
Describe the risks of ionizing radiation in children and review the concept of ALARA (as low as reasonably achievable) in limiting radiation exposure.
Review the indications for and benefits and risks of oral and intravenous contrast.
Review the indications for anxiolysis, sedation, and anaesthesia attending to age, developmental stage, and procedure being performed.
Compare and contrast indications for interventional radiologist versus general surgical consultation.
Discuss the role of the radiologist as consultant.
Discuss the appropriate imaging modality selection(s) for common emergent clinical presentations such as altered mental status, stridor, potential bowel obstruction, and others.
Compare and contrast the utility, risks, and costs of different imaging modalities for presentations of complicated pneumonia and acute abdominal pain.
Skills
Pediatric hospitalists should be able to:
Correctly determine the optimal study to answer a specific clinical question in a cost‐effective manner, accounting for the limitations and risks of the study.
Accurately order radiologic studies, noting indications for the study, sedation/anaesthesia need, and other relevant information in the order.
Engage the radiologist as consultant as appropriate.
Accurately interpret plain radiographs of the chest and abdomen for children 0‐18 years of age.
Correctly identify the need for and efficiently access interventional radiologists as appropriate.
Communicate effectively with the healthcare team including radiologist and anaesthesiologist (as appropriate) to ensure safe, efficient and effective performance of radiologic studies.
Correctly interpret and apply the results of radiographic studies into clinical care plans.
Attitudes
Pediatric hospitalists should be able to:
Elicit and allay common family/caregiver concerns regarding radiation risks.
Work collaboratively with hospital staff, radiologists, and anaesthesiologists to ensure coordinated planning and performance of radiologic studies.
Communicate effectively with patients and the family/caregiver regarding the indications for, risks, benefits, and steps involved in the radiologic procedure.
Recognize the importance of obtaining results of all studies and reviewing images in person whenever possible.
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 standards for radiology services for children.
Work with hospital administration to assure that a reliable and efficient radiographic imaging service is available for pediatric inpatients at the local facility.
Lead, coordinate or participate in development and implementation of a system to review the accuracy of readings for pediatric patients and develop local criteria for tertiary referral center consultation.
Collaborate with hospital administration and community partners to develop and sustain referral networks between local facilities and tertiary referral centers that enable review of appropriately selected pediatric images.
Work with hospital administration, subspecialists, and others to review acquisition of new technologies and assess the impact on patient care.
Introduction
Radiographic studies are commonly performed throughout a wide range of pediatric healthcare settings. Imaging can play a pivotal role in the acute and chronic medical and surgical management of ill children. The explosion of imaging technology and expertise in the past three decades has resulted in an increased array of imaging modalities from which to choose. Access to and interpretation of imaging studies for children varies greatly between facilities. Pediatric hospitalists frequently encounter patients requiring imaging studies, and should be adept at ordering and interpreting images in collaboration with radiologist and other subspecialists.
Knowledge
Pediatric hospitalists should be able to:
Review basic human anatomy and relate this to interpretation of common plain radiographs of areas such as the chest, abdomen, airway, and long bones.
Describe the indications and limitations of the common radiographic modalities such as sonography, computed tomography, magnetic resonance imaging, plain radiography, and bone scans.
Describe the risks of ionizing radiation in children and review the concept of ALARA (as low as reasonably achievable) in limiting radiation exposure.
Review the indications for and benefits and risks of oral and intravenous contrast.
Review the indications for anxiolysis, sedation, and anaesthesia attending to age, developmental stage, and procedure being performed.
Compare and contrast indications for interventional radiologist versus general surgical consultation.
Discuss the role of the radiologist as consultant.
Discuss the appropriate imaging modality selection(s) for common emergent clinical presentations such as altered mental status, stridor, potential bowel obstruction, and others.
Compare and contrast the utility, risks, and costs of different imaging modalities for presentations of complicated pneumonia and acute abdominal pain.
Skills
Pediatric hospitalists should be able to:
Correctly determine the optimal study to answer a specific clinical question in a cost‐effective manner, accounting for the limitations and risks of the study.
Accurately order radiologic studies, noting indications for the study, sedation/anaesthesia need, and other relevant information in the order.
Engage the radiologist as consultant as appropriate.
Accurately interpret plain radiographs of the chest and abdomen for children 0‐18 years of age.
Correctly identify the need for and efficiently access interventional radiologists as appropriate.
Communicate effectively with the healthcare team including radiologist and anaesthesiologist (as appropriate) to ensure safe, efficient and effective performance of radiologic studies.
Correctly interpret and apply the results of radiographic studies into clinical care plans.
Attitudes
Pediatric hospitalists should be able to:
Elicit and allay common family/caregiver concerns regarding radiation risks.
Work collaboratively with hospital staff, radiologists, and anaesthesiologists to ensure coordinated planning and performance of radiologic studies.
Communicate effectively with patients and the family/caregiver regarding the indications for, risks, benefits, and steps involved in the radiologic procedure.
Recognize the importance of obtaining results of all studies and reviewing images in person whenever possible.
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 standards for radiology services for children.
Work with hospital administration to assure that a reliable and efficient radiographic imaging service is available for pediatric inpatients at the local facility.
Lead, coordinate or participate in development and implementation of a system to review the accuracy of readings for pediatric patients and develop local criteria for tertiary referral center consultation.
Collaborate with hospital administration and community partners to develop and sustain referral networks between local facilities and tertiary referral centers that enable review of appropriately selected pediatric images.
Work with hospital administration, subspecialists, and others to review acquisition of new technologies and assess the impact on patient care.
Copyright © 2010 Society of Hospital Medicine
Communication
Introduction
Communication is defined as any process in which a message containing information is transferred, especially from one person to another, via any of a number of media. Communication may be delivered verbally or non‐verbally, directly, (as in face‐to‐face conversation or with the observation of a gesture) or remotely, spanning space and time (as in writing, reading, making or playing back a recording, or using a computer). Pediatric hospitalists must be effective communicators in many venues such as when rendering direct patient care, performing hospital committee work, or educating trainees. However, the most important of these is the verbal communication that occurs at the bedside with patients, family/caregiver, and healthcare team. Successful patient care is elusive or wanting without proper communication.
Knowledge
Pediatric hospitalists should be able to:
Compare and contrast the importance of listening and speaking for effective communication.
Define the components of effective expressive and receptive (listening) communication, such as introduction of team members, avoiding medical jargon, tone, word choice, allowing time for patients and the family/caregiver to speak, and body language.
List examples of common non‐listening behaviors such as allowing distractions, asking unrelated questions, jumping to conclusions, interrupting the speaker, and failing to notice the speaker's non‐verbal language.
Cite methods that can be used when faced with difficult behaviors during communication, such as asking for a behavior change and paraphrasing to diffuse emotion.
Describe patients in a cultural and spiritual context.
Explain how vulnerabilities, life situation, limitation in activities of daily living, education, language and other factors should each be addressed when communicating with patients and the family/caregiver.
Identify personal values, biases, skills, and relationships that may influence communication.
Discuss the significance of including the family/caregiver and others who are most important to patients in patient care discussions.
Explain why effective communication is central to patient care handoffs and list examples of best methods for communication both within hospitalist groups and with other healthcare providers.
Articulate how to give bad news by expressing empathy, giving patients and the family/caregiver time to ask questions, maintaining calm, and choosing a quiet, private location for the discussion.
Cite important features of effective written communication.
Compare and contrast specific examples of effective and ineffective written communication, including timing of entries, legibility, disagreements on patient care decisions, documentation of changes in clinical status and others.
Skills
Pediatric hospitalists should be able to:
Demonstrate command of a comprehensive array of expressive and receptive communication skills.
Coordinate discussions with all caregivers to ensure a single clear message is given to patients and the family/caregiver.
Actively participate in conflict resolution.
Summarize the entire process and sequence of care for patients and the family/caregiver in understandable terms following the principles of family centered care.
Maintain concise, complete written records that meet expectations of external reviewing agencies and malpractice carriers.
Develop and implement a plan for daily communication that is family centered.
Attitudes
Pediatric hospitalists should be able to:
Respect the skills and contributions of all involved in the care of patients.
Exemplify professionalism in all communications.
Seek opportunities to enhance communication skills.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Collaborate with hospital administrators to improve medical record documentation systems by technical means.
Assist in the development of and/or participate in hospital and system‐wide educational programs on communication skills.
Introduction
Communication is defined as any process in which a message containing information is transferred, especially from one person to another, via any of a number of media. Communication may be delivered verbally or non‐verbally, directly, (as in face‐to‐face conversation or with the observation of a gesture) or remotely, spanning space and time (as in writing, reading, making or playing back a recording, or using a computer). Pediatric hospitalists must be effective communicators in many venues such as when rendering direct patient care, performing hospital committee work, or educating trainees. However, the most important of these is the verbal communication that occurs at the bedside with patients, family/caregiver, and healthcare team. Successful patient care is elusive or wanting without proper communication.
Knowledge
Pediatric hospitalists should be able to:
Compare and contrast the importance of listening and speaking for effective communication.
Define the components of effective expressive and receptive (listening) communication, such as introduction of team members, avoiding medical jargon, tone, word choice, allowing time for patients and the family/caregiver to speak, and body language.
List examples of common non‐listening behaviors such as allowing distractions, asking unrelated questions, jumping to conclusions, interrupting the speaker, and failing to notice the speaker's non‐verbal language.
Cite methods that can be used when faced with difficult behaviors during communication, such as asking for a behavior change and paraphrasing to diffuse emotion.
Describe patients in a cultural and spiritual context.
Explain how vulnerabilities, life situation, limitation in activities of daily living, education, language and other factors should each be addressed when communicating with patients and the family/caregiver.
Identify personal values, biases, skills, and relationships that may influence communication.
Discuss the significance of including the family/caregiver and others who are most important to patients in patient care discussions.
Explain why effective communication is central to patient care handoffs and list examples of best methods for communication both within hospitalist groups and with other healthcare providers.
Articulate how to give bad news by expressing empathy, giving patients and the family/caregiver time to ask questions, maintaining calm, and choosing a quiet, private location for the discussion.
Cite important features of effective written communication.
Compare and contrast specific examples of effective and ineffective written communication, including timing of entries, legibility, disagreements on patient care decisions, documentation of changes in clinical status and others.
Skills
Pediatric hospitalists should be able to:
Demonstrate command of a comprehensive array of expressive and receptive communication skills.
Coordinate discussions with all caregivers to ensure a single clear message is given to patients and the family/caregiver.
Actively participate in conflict resolution.
Summarize the entire process and sequence of care for patients and the family/caregiver in understandable terms following the principles of family centered care.
Maintain concise, complete written records that meet expectations of external reviewing agencies and malpractice carriers.
Develop and implement a plan for daily communication that is family centered.
Attitudes
Pediatric hospitalists should be able to:
Respect the skills and contributions of all involved in the care of patients.
Exemplify professionalism in all communications.
Seek opportunities to enhance communication skills.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Collaborate with hospital administrators to improve medical record documentation systems by technical means.
Assist in the development of and/or participate in hospital and system‐wide educational programs on communication skills.
Introduction
Communication is defined as any process in which a message containing information is transferred, especially from one person to another, via any of a number of media. Communication may be delivered verbally or non‐verbally, directly, (as in face‐to‐face conversation or with the observation of a gesture) or remotely, spanning space and time (as in writing, reading, making or playing back a recording, or using a computer). Pediatric hospitalists must be effective communicators in many venues such as when rendering direct patient care, performing hospital committee work, or educating trainees. However, the most important of these is the verbal communication that occurs at the bedside with patients, family/caregiver, and healthcare team. Successful patient care is elusive or wanting without proper communication.
Knowledge
Pediatric hospitalists should be able to:
Compare and contrast the importance of listening and speaking for effective communication.
Define the components of effective expressive and receptive (listening) communication, such as introduction of team members, avoiding medical jargon, tone, word choice, allowing time for patients and the family/caregiver to speak, and body language.
List examples of common non‐listening behaviors such as allowing distractions, asking unrelated questions, jumping to conclusions, interrupting the speaker, and failing to notice the speaker's non‐verbal language.
Cite methods that can be used when faced with difficult behaviors during communication, such as asking for a behavior change and paraphrasing to diffuse emotion.
Describe patients in a cultural and spiritual context.
Explain how vulnerabilities, life situation, limitation in activities of daily living, education, language and other factors should each be addressed when communicating with patients and the family/caregiver.
Identify personal values, biases, skills, and relationships that may influence communication.
Discuss the significance of including the family/caregiver and others who are most important to patients in patient care discussions.
Explain why effective communication is central to patient care handoffs and list examples of best methods for communication both within hospitalist groups and with other healthcare providers.
Articulate how to give bad news by expressing empathy, giving patients and the family/caregiver time to ask questions, maintaining calm, and choosing a quiet, private location for the discussion.
Cite important features of effective written communication.
Compare and contrast specific examples of effective and ineffective written communication, including timing of entries, legibility, disagreements on patient care decisions, documentation of changes in clinical status and others.
Skills
Pediatric hospitalists should be able to:
Demonstrate command of a comprehensive array of expressive and receptive communication skills.
Coordinate discussions with all caregivers to ensure a single clear message is given to patients and the family/caregiver.
Actively participate in conflict resolution.
Summarize the entire process and sequence of care for patients and the family/caregiver in understandable terms following the principles of family centered care.
Maintain concise, complete written records that meet expectations of external reviewing agencies and malpractice carriers.
Develop and implement a plan for daily communication that is family centered.
Attitudes
Pediatric hospitalists should be able to:
Respect the skills and contributions of all involved in the care of patients.
Exemplify professionalism in all communications.
Seek opportunities to enhance communication skills.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Collaborate with hospital administrators to improve medical record documentation systems by technical means.
Assist in the development of and/or participate in hospital and system‐wide educational programs on communication skills.
Copyright © 2010 Society of Hospital Medicine
Shock
Introduction
Early recognition and treatment of shock is imperative in improving the outcomes of critically ill children. The American Heart Association categorizes shock into four basic forms: hypovolemic, distributive, cardiogenic, and obstructive. Shock results from inadequate tissue perfusion to support metabolic demands. This may be caused by an inadequate supply of oxygen to the tissues or an increased demand of the tissues for oxygen. As a result, cellular hypoxia, anaerobic metabolism, and dysregulation result in irreversible cell damage and death. Pediatric hospitalists often encounter children with all forms of shock and should be adept at recognition and basic management of shock to improve outcomes.
Knowledge
Pediatric hospitalists should be able to:
Discuss the pathophysiology of tissue hypoxia including hypoxemia, anemia, and ischemia.
Describe the components of tissue oxygen delivery, focusing on cardiac output.
Describe common diseases and conditions associated with the four forms of shock.
Compare and contrast the presenting signs and symptoms of the four forms of shock, attending to differences in heart rate, blood pressure, pulses and peripheral perfusion, mental status, and urine output.
Discuss compensatory mechanisms of early shock including increased heart rate, stroke volume, and vascular smooth muscle tone.
List indications for chronotropic, inotropic, and blood pressure support and describe the mechanisms of action for these classes of medications.
State the commonly performed diagnostic studies (such as lab, radiographic, and other) which aid in determining the extent or form of shock.
Summarize the approach toward stabilization of each form of shock.
Skills
Pediatric hospitalists should be able to:
Perform an initial rapid assessment using Pediatric Advanced Life Support skills.
Recognize signs of early shock and respond with appropriate actions.
Appropriately order and correctly interpret results of common studies to determine the extent of shock such as complete blood count, chemistries, blood gas, radiography and others.
Appropriately order and correctly interpret results of studies to determine the cause of shock and respond with appropriate actions.
Order appropriate monitoring and correctly interpret monitor data.
Correctly recognize cardiomegaly and other signs of congestive heart failure on chest radiograph.
Correctly identify the form of shock from a focused history, physical examination and initial diagnostic studies.
Initiate appropriate interventions based on the form of shock.
Facilitate effective transfer to a tertiary care center or intensive care setting when appropriate.
Attitudes
Pediatric hospitalists should be able to:
Communicate effectively with emergency room and intensive care staff to ensure appropriate care for patients in shock.
Listen effectively and respond to concerns of the family/caregiver and healthcare providers regarding changes in physiologic parameters including vital signs, mental status, physical examination, and urine output.
Provide family/caregiver support and education on the nuances and complexities of the various forms of shock and the importance of careful monitoring and evaluation.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Work with hospital administration, hospital staff, subspecialists, and other services to advocate for an educational program for healthcare providers on the importance of early recognition of shock to prevent end‐organ failure and death.
Lead, coordinate or participate in the development and implementation of rapid response systems to assist in recognition and stabilization of early shock.
Collaborate with hospital administration and community partners to develop and sustain local AHA Pediatric Life Support classes where descriptions and case scenarios provide a comprehensive knowledge base and intervention plan for various types of shock.
Lead, coordinate or participate in efforts to partner with simulation centers to assist in acquiring skill sets needed for appropriate recognition and intervention for children in shock.
Introduction
Early recognition and treatment of shock is imperative in improving the outcomes of critically ill children. The American Heart Association categorizes shock into four basic forms: hypovolemic, distributive, cardiogenic, and obstructive. Shock results from inadequate tissue perfusion to support metabolic demands. This may be caused by an inadequate supply of oxygen to the tissues or an increased demand of the tissues for oxygen. As a result, cellular hypoxia, anaerobic metabolism, and dysregulation result in irreversible cell damage and death. Pediatric hospitalists often encounter children with all forms of shock and should be adept at recognition and basic management of shock to improve outcomes.
Knowledge
Pediatric hospitalists should be able to:
Discuss the pathophysiology of tissue hypoxia including hypoxemia, anemia, and ischemia.
Describe the components of tissue oxygen delivery, focusing on cardiac output.
Describe common diseases and conditions associated with the four forms of shock.
Compare and contrast the presenting signs and symptoms of the four forms of shock, attending to differences in heart rate, blood pressure, pulses and peripheral perfusion, mental status, and urine output.
Discuss compensatory mechanisms of early shock including increased heart rate, stroke volume, and vascular smooth muscle tone.
List indications for chronotropic, inotropic, and blood pressure support and describe the mechanisms of action for these classes of medications.
State the commonly performed diagnostic studies (such as lab, radiographic, and other) which aid in determining the extent or form of shock.
Summarize the approach toward stabilization of each form of shock.
Skills
Pediatric hospitalists should be able to:
Perform an initial rapid assessment using Pediatric Advanced Life Support skills.
Recognize signs of early shock and respond with appropriate actions.
Appropriately order and correctly interpret results of common studies to determine the extent of shock such as complete blood count, chemistries, blood gas, radiography and others.
Appropriately order and correctly interpret results of studies to determine the cause of shock and respond with appropriate actions.
Order appropriate monitoring and correctly interpret monitor data.
Correctly recognize cardiomegaly and other signs of congestive heart failure on chest radiograph.
Correctly identify the form of shock from a focused history, physical examination and initial diagnostic studies.
Initiate appropriate interventions based on the form of shock.
Facilitate effective transfer to a tertiary care center or intensive care setting when appropriate.
Attitudes
Pediatric hospitalists should be able to:
Communicate effectively with emergency room and intensive care staff to ensure appropriate care for patients in shock.
Listen effectively and respond to concerns of the family/caregiver and healthcare providers regarding changes in physiologic parameters including vital signs, mental status, physical examination, and urine output.
Provide family/caregiver support and education on the nuances and complexities of the various forms of shock and the importance of careful monitoring and evaluation.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Work with hospital administration, hospital staff, subspecialists, and other services to advocate for an educational program for healthcare providers on the importance of early recognition of shock to prevent end‐organ failure and death.
Lead, coordinate or participate in the development and implementation of rapid response systems to assist in recognition and stabilization of early shock.
Collaborate with hospital administration and community partners to develop and sustain local AHA Pediatric Life Support classes where descriptions and case scenarios provide a comprehensive knowledge base and intervention plan for various types of shock.
Lead, coordinate or participate in efforts to partner with simulation centers to assist in acquiring skill sets needed for appropriate recognition and intervention for children in shock.
Introduction
Early recognition and treatment of shock is imperative in improving the outcomes of critically ill children. The American Heart Association categorizes shock into four basic forms: hypovolemic, distributive, cardiogenic, and obstructive. Shock results from inadequate tissue perfusion to support metabolic demands. This may be caused by an inadequate supply of oxygen to the tissues or an increased demand of the tissues for oxygen. As a result, cellular hypoxia, anaerobic metabolism, and dysregulation result in irreversible cell damage and death. Pediatric hospitalists often encounter children with all forms of shock and should be adept at recognition and basic management of shock to improve outcomes.
Knowledge
Pediatric hospitalists should be able to:
Discuss the pathophysiology of tissue hypoxia including hypoxemia, anemia, and ischemia.
Describe the components of tissue oxygen delivery, focusing on cardiac output.
Describe common diseases and conditions associated with the four forms of shock.
Compare and contrast the presenting signs and symptoms of the four forms of shock, attending to differences in heart rate, blood pressure, pulses and peripheral perfusion, mental status, and urine output.
Discuss compensatory mechanisms of early shock including increased heart rate, stroke volume, and vascular smooth muscle tone.
List indications for chronotropic, inotropic, and blood pressure support and describe the mechanisms of action for these classes of medications.
State the commonly performed diagnostic studies (such as lab, radiographic, and other) which aid in determining the extent or form of shock.
Summarize the approach toward stabilization of each form of shock.
Skills
Pediatric hospitalists should be able to:
Perform an initial rapid assessment using Pediatric Advanced Life Support skills.
Recognize signs of early shock and respond with appropriate actions.
Appropriately order and correctly interpret results of common studies to determine the extent of shock such as complete blood count, chemistries, blood gas, radiography and others.
Appropriately order and correctly interpret results of studies to determine the cause of shock and respond with appropriate actions.
Order appropriate monitoring and correctly interpret monitor data.
Correctly recognize cardiomegaly and other signs of congestive heart failure on chest radiograph.
Correctly identify the form of shock from a focused history, physical examination and initial diagnostic studies.
Initiate appropriate interventions based on the form of shock.
Facilitate effective transfer to a tertiary care center or intensive care setting when appropriate.
Attitudes
Pediatric hospitalists should be able to:
Communicate effectively with emergency room and intensive care staff to ensure appropriate care for patients in shock.
Listen effectively and respond to concerns of the family/caregiver and healthcare providers regarding changes in physiologic parameters including vital signs, mental status, physical examination, and urine output.
Provide family/caregiver support and education on the nuances and complexities of the various forms of shock and the importance of careful monitoring and evaluation.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Work with hospital administration, hospital staff, subspecialists, and other services to advocate for an educational program for healthcare providers on the importance of early recognition of shock to prevent end‐organ failure and death.
Lead, coordinate or participate in the development and implementation of rapid response systems to assist in recognition and stabilization of early shock.
Collaborate with hospital administration and community partners to develop and sustain local AHA Pediatric Life Support classes where descriptions and case scenarios provide a comprehensive knowledge base and intervention plan for various types of shock.
Lead, coordinate or participate in efforts to partner with simulation centers to assist in acquiring skill sets needed for appropriate recognition and intervention for children in shock.
Copyright © 2010 Society of Hospital Medicine
Feeding tubes
Introduction
Feeding tubes are commonly used to deliver enteral nutrition and medications to pediatric inpatients. Commonly used tubes are nasogastric (NG), nasojejunal (NJ), gastric (G), gastrojejunal (GJ), or jejunal (J). They may be used instead of or in addition to oral feedings. Feeding tubes may deliver nutrition and medications into the stomach or past the pylorus. While different types of feeding tubes may be placed by a variety of practitioners ‐ nurses, radiologists, medical physicians, or surgeons ‐ it is critical for pediatric hospitalists to understand the uses, limitations, and complications of various types of feeding tubes.
Knowledge
Pediatric hospitalists should be able to:
Describe basic gastrointestinal anatomy and physiology, and relate this to commonly used feeding tubes.
Compare and contrast the indications, uses, and limitations of various types of feeding tubes, including NG, NJ, G, GJ, and J tubes.
Discuss the benefits of short term enteral feeding compared to intravenous fluid or parenteral nutrition use.
Describe the correct procedure to replace each type of feeding tube and potential complications to be avoided.
Review commonly encountered short and long term complications of feeding tubes, such as nasal irritation, granulation tissue, cellulitis, extrusion, obstruction, and others.
Compare and contrast risks and benefits of percutaneous endoscopic gastrostomy (PEG) versus surgical gastrostomy.
List the indications, risks, benefits, and alternatives for surgical gastrostomy with Nissen fundoplication.
Discuss the factors to consider when determining the optimal type of feeding tube for children with neurologic impairment, such as risk of aspiration pneumonia, social aspects of maintaining oral stimulation, complications of Nissen fundoplication, and others.
Compare and contrast the short and long term risks and benefits of gastrostomy with Nissen fundoplication versus placement of GJ tubes in patients with neurologic impairment.
Discuss the roles of primary care provider, home care, subspecialists, and the family/caregiver in the home management of feeding tubes.
Skills
Pediatric hospitalists should be able to:
Correctly institute short term NG feeding in appropriate patients.
Appropriately prescribe NG or NJ feeding, including correct starting and increasing volumes and enteral formula choice.
Correctly identify and refer appropriate patients for a G tube, GJ tube, or J tube placement.
Effectively and clearly articulate the risks and benefits of combining Nissen Fundoplication with G tube placement vs. GJ tube placement to the family/caregiver.
Accurately diagnose and treat dermatological problems associated with feeding tubes.
Accurately diagnose and initiate treatment for common complications (obstruction, extrusion, leakage) associated with feeding tubes, in collaboration with appropriate subspecialists.
Order appropriate radiological studies to assess feeding tube dysfunction.
Demonstrate basic proficiency in interpretation of radiographic studies commonly performed to assess correct tube placement.
Correctly identify the need for and efficiently access appropriate consultants.
Attitudes
Pediatric hospitalists should be able to:
Work collaboratively with patients, family/caregiver, hospital staff, subspecialists and the primary care provider in making decisions regarding feeding tubes.
Elicit and allay concerns of patients and the family/caregiver regarding the cosmetic appearance of tubes or impact on oral feeding.
Educate patients and the family/caregiver about the use and care of feeding tubes prior to discharge home.
Recognize the key role that home health care plays in the discharge planning and long term care of children with feeding tubes.
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 feeding tubes for children.
Collaborate with hospital administration and community partners to develop and sustain local systems that organize and consolidate the feeding tube supplies and services for children in an identifiable, easily accessible location.
Lead, coordinate or participate in efforts to develop strategies to minimize institutional complication rates from feeding tube placement and use.
Lead, coordinate or participate in multidisciplinary efforts to develop an education and hospital discharge protocol to ensure that patients with feeding tubes are safely transitioned to the outpatient setting.
Introduction
Feeding tubes are commonly used to deliver enteral nutrition and medications to pediatric inpatients. Commonly used tubes are nasogastric (NG), nasojejunal (NJ), gastric (G), gastrojejunal (GJ), or jejunal (J). They may be used instead of or in addition to oral feedings. Feeding tubes may deliver nutrition and medications into the stomach or past the pylorus. While different types of feeding tubes may be placed by a variety of practitioners ‐ nurses, radiologists, medical physicians, or surgeons ‐ it is critical for pediatric hospitalists to understand the uses, limitations, and complications of various types of feeding tubes.
Knowledge
Pediatric hospitalists should be able to:
Describe basic gastrointestinal anatomy and physiology, and relate this to commonly used feeding tubes.
Compare and contrast the indications, uses, and limitations of various types of feeding tubes, including NG, NJ, G, GJ, and J tubes.
Discuss the benefits of short term enteral feeding compared to intravenous fluid or parenteral nutrition use.
Describe the correct procedure to replace each type of feeding tube and potential complications to be avoided.
Review commonly encountered short and long term complications of feeding tubes, such as nasal irritation, granulation tissue, cellulitis, extrusion, obstruction, and others.
Compare and contrast risks and benefits of percutaneous endoscopic gastrostomy (PEG) versus surgical gastrostomy.
List the indications, risks, benefits, and alternatives for surgical gastrostomy with Nissen fundoplication.
Discuss the factors to consider when determining the optimal type of feeding tube for children with neurologic impairment, such as risk of aspiration pneumonia, social aspects of maintaining oral stimulation, complications of Nissen fundoplication, and others.
Compare and contrast the short and long term risks and benefits of gastrostomy with Nissen fundoplication versus placement of GJ tubes in patients with neurologic impairment.
Discuss the roles of primary care provider, home care, subspecialists, and the family/caregiver in the home management of feeding tubes.
Skills
Pediatric hospitalists should be able to:
Correctly institute short term NG feeding in appropriate patients.
Appropriately prescribe NG or NJ feeding, including correct starting and increasing volumes and enteral formula choice.
Correctly identify and refer appropriate patients for a G tube, GJ tube, or J tube placement.
Effectively and clearly articulate the risks and benefits of combining Nissen Fundoplication with G tube placement vs. GJ tube placement to the family/caregiver.
Accurately diagnose and treat dermatological problems associated with feeding tubes.
Accurately diagnose and initiate treatment for common complications (obstruction, extrusion, leakage) associated with feeding tubes, in collaboration with appropriate subspecialists.
Order appropriate radiological studies to assess feeding tube dysfunction.
Demonstrate basic proficiency in interpretation of radiographic studies commonly performed to assess correct tube placement.
Correctly identify the need for and efficiently access appropriate consultants.
Attitudes
Pediatric hospitalists should be able to:
Work collaboratively with patients, family/caregiver, hospital staff, subspecialists and the primary care provider in making decisions regarding feeding tubes.
Elicit and allay concerns of patients and the family/caregiver regarding the cosmetic appearance of tubes or impact on oral feeding.
Educate patients and the family/caregiver about the use and care of feeding tubes prior to discharge home.
Recognize the key role that home health care plays in the discharge planning and long term care of children with feeding tubes.
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 feeding tubes for children.
Collaborate with hospital administration and community partners to develop and sustain local systems that organize and consolidate the feeding tube supplies and services for children in an identifiable, easily accessible location.
Lead, coordinate or participate in efforts to develop strategies to minimize institutional complication rates from feeding tube placement and use.
Lead, coordinate or participate in multidisciplinary efforts to develop an education and hospital discharge protocol to ensure that patients with feeding tubes are safely transitioned to the outpatient setting.
Introduction
Feeding tubes are commonly used to deliver enteral nutrition and medications to pediatric inpatients. Commonly used tubes are nasogastric (NG), nasojejunal (NJ), gastric (G), gastrojejunal (GJ), or jejunal (J). They may be used instead of or in addition to oral feedings. Feeding tubes may deliver nutrition and medications into the stomach or past the pylorus. While different types of feeding tubes may be placed by a variety of practitioners ‐ nurses, radiologists, medical physicians, or surgeons ‐ it is critical for pediatric hospitalists to understand the uses, limitations, and complications of various types of feeding tubes.
Knowledge
Pediatric hospitalists should be able to:
Describe basic gastrointestinal anatomy and physiology, and relate this to commonly used feeding tubes.
Compare and contrast the indications, uses, and limitations of various types of feeding tubes, including NG, NJ, G, GJ, and J tubes.
Discuss the benefits of short term enteral feeding compared to intravenous fluid or parenteral nutrition use.
Describe the correct procedure to replace each type of feeding tube and potential complications to be avoided.
Review commonly encountered short and long term complications of feeding tubes, such as nasal irritation, granulation tissue, cellulitis, extrusion, obstruction, and others.
Compare and contrast risks and benefits of percutaneous endoscopic gastrostomy (PEG) versus surgical gastrostomy.
List the indications, risks, benefits, and alternatives for surgical gastrostomy with Nissen fundoplication.
Discuss the factors to consider when determining the optimal type of feeding tube for children with neurologic impairment, such as risk of aspiration pneumonia, social aspects of maintaining oral stimulation, complications of Nissen fundoplication, and others.
Compare and contrast the short and long term risks and benefits of gastrostomy with Nissen fundoplication versus placement of GJ tubes in patients with neurologic impairment.
Discuss the roles of primary care provider, home care, subspecialists, and the family/caregiver in the home management of feeding tubes.
Skills
Pediatric hospitalists should be able to:
Correctly institute short term NG feeding in appropriate patients.
Appropriately prescribe NG or NJ feeding, including correct starting and increasing volumes and enteral formula choice.
Correctly identify and refer appropriate patients for a G tube, GJ tube, or J tube placement.
Effectively and clearly articulate the risks and benefits of combining Nissen Fundoplication with G tube placement vs. GJ tube placement to the family/caregiver.
Accurately diagnose and treat dermatological problems associated with feeding tubes.
Accurately diagnose and initiate treatment for common complications (obstruction, extrusion, leakage) associated with feeding tubes, in collaboration with appropriate subspecialists.
Order appropriate radiological studies to assess feeding tube dysfunction.
Demonstrate basic proficiency in interpretation of radiographic studies commonly performed to assess correct tube placement.
Correctly identify the need for and efficiently access appropriate consultants.
Attitudes
Pediatric hospitalists should be able to:
Work collaboratively with patients, family/caregiver, hospital staff, subspecialists and the primary care provider in making decisions regarding feeding tubes.
Elicit and allay concerns of patients and the family/caregiver regarding the cosmetic appearance of tubes or impact on oral feeding.
Educate patients and the family/caregiver about the use and care of feeding tubes prior to discharge home.
Recognize the key role that home health care plays in the discharge planning and long term care of children with feeding tubes.
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 feeding tubes for children.
Collaborate with hospital administration and community partners to develop and sustain local systems that organize and consolidate the feeding tube supplies and services for children in an identifiable, easily accessible location.
Lead, coordinate or participate in efforts to develop strategies to minimize institutional complication rates from feeding tube placement and use.
Lead, coordinate or participate in multidisciplinary efforts to develop an education and hospital discharge protocol to ensure that patients with feeding tubes are safely transitioned to the outpatient setting.
Copyright © 2010 Society of Hospital Medicine
Apparent life‐threatening event
Introduction
Apparent Life‐Threatening Event (ALTE) is defined by the NIH Consensus Development Conference on Infantile Apnea and Home Monitoring as an episode that is frightening to the observer and that is characterized by some combination of apnea (central or occasionally obstructive), color change (usually cyanotic or pallid but occasionally erythematous or plethoric), marked change in muscle tone (usually marked limpness), choking, or gagging. Because ALTE is a description of symptoms rather than a diagnosis, epidemiologic data is imprecise. It is estimated that 1‐3% of infants will have an episode that can be described as an ALTE and that most of these infants present before 2 months of life. Pediatric hospitalists can provide a valuable service to the family/caregiver by reconciling the potentially life threatening nature of ALTE with an infant who often appears normal on physical examination. Pediatric hospitalists should approach the broad differential diagnosis in a logical, systematic manner.
Knowledge
Pediatric hospitalists should be able to:
Describe the differential diagnosis of ALTE (such as gastroesophageal reflux disease, seizure, apnea of prematurity, infection [sepsis, meningitis, pertussis, bronchiolitis], toxin, breath‐holding spell, cardiac arrhythmia, obstructive sleep apnea, inborn errors of metabolism, central hypoventilation syndrome, hydrocephalus, child abuse, Munchausen's Syndrome by Proxy, and others) and the key historical or physical findings specifically associated with each diagnosis.
Provide indications for admission to the hospital and determine the appropriate level of care required.
Describe the goals of hospitalization including stabilization, diagnosis, treatment, reassurance, and education.
Compare and contrast Sudden Infant Death Syndrome (SIDS) versus ALTE,
Discuss current hypotheses regarding the etiology of SIDS and relate this to the spectrum of disorders that may cause ALTE.
Describe a basic approach toward the work‐up for ALTE and list the factors that may warrant an increased level of laboratory, radiographic, or other testing.
Summarize the literature on the impact of home monitors on morbidity and mortality and identify the benefits and limitations of home monitoring.
Skills
Pediatric hospitalists should be able to:
Resuscitate and stabilize an infant with ALTE who presents in an unstable state.
Obtain an accurate patient history and perform a thorough physical examination eliciting features to narrow the differential diagnosis of ALTE.
Critically assess the level of evidence and risk/benefit ratio for the diagnostic work‐up and management plan.
Interpret basic tests (such as laboratory tests, chest x‐rays, and electrocardiograms) and identify abnormal findings that require further testing or consultation.
Order appropriate monitoring and correctly interpret monitor data.
Engage consultants and support staff (such as subspecialty physicians and social workers) efficiently and appropriately.
Use the ALTE admission as an opportunity to educate the family/caregiver on proper sleep positioning and risk factors for SIDS.
Impart basic resuscitation skills to the family/caregiver, using a teach‐back method.
Coordinate care with the primary care provider and arrange an appropriate transition plan for hospital discharge.
Attitudes
Pediatric hospitalists should be able to:
Communicate effectively with the family/caregiver, and healthcare providers regarding findings and care plans.
Ensure a safe and supportive atmosphere for the patient and family during the period of observation and evaluation of a child admitted following an ALTE.
Counsel the family/caregiver on the valid use of home monitors in a limited population, noting the features which support or refute use of a home monitor for their child.
Realize the impact of an ALTE on the family/caregiver and the implications for discharge planning and follow‐up.
Role model professional behavior when addressing issues related to potential social concerns and child abuse evaluation.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Lead, coordinate or participate in multidisciplinary initiatives to develop and implement evidence‐based clinical guidelines to improve quality of care for infants with ALTE.
Advocate for preventive education regarding sudden infant death syndrome in the hospital system and community.
Introduction
Apparent Life‐Threatening Event (ALTE) is defined by the NIH Consensus Development Conference on Infantile Apnea and Home Monitoring as an episode that is frightening to the observer and that is characterized by some combination of apnea (central or occasionally obstructive), color change (usually cyanotic or pallid but occasionally erythematous or plethoric), marked change in muscle tone (usually marked limpness), choking, or gagging. Because ALTE is a description of symptoms rather than a diagnosis, epidemiologic data is imprecise. It is estimated that 1‐3% of infants will have an episode that can be described as an ALTE and that most of these infants present before 2 months of life. Pediatric hospitalists can provide a valuable service to the family/caregiver by reconciling the potentially life threatening nature of ALTE with an infant who often appears normal on physical examination. Pediatric hospitalists should approach the broad differential diagnosis in a logical, systematic manner.
Knowledge
Pediatric hospitalists should be able to:
Describe the differential diagnosis of ALTE (such as gastroesophageal reflux disease, seizure, apnea of prematurity, infection [sepsis, meningitis, pertussis, bronchiolitis], toxin, breath‐holding spell, cardiac arrhythmia, obstructive sleep apnea, inborn errors of metabolism, central hypoventilation syndrome, hydrocephalus, child abuse, Munchausen's Syndrome by Proxy, and others) and the key historical or physical findings specifically associated with each diagnosis.
Provide indications for admission to the hospital and determine the appropriate level of care required.
Describe the goals of hospitalization including stabilization, diagnosis, treatment, reassurance, and education.
Compare and contrast Sudden Infant Death Syndrome (SIDS) versus ALTE,
Discuss current hypotheses regarding the etiology of SIDS and relate this to the spectrum of disorders that may cause ALTE.
Describe a basic approach toward the work‐up for ALTE and list the factors that may warrant an increased level of laboratory, radiographic, or other testing.
Summarize the literature on the impact of home monitors on morbidity and mortality and identify the benefits and limitations of home monitoring.
Skills
Pediatric hospitalists should be able to:
Resuscitate and stabilize an infant with ALTE who presents in an unstable state.
Obtain an accurate patient history and perform a thorough physical examination eliciting features to narrow the differential diagnosis of ALTE.
Critically assess the level of evidence and risk/benefit ratio for the diagnostic work‐up and management plan.
Interpret basic tests (such as laboratory tests, chest x‐rays, and electrocardiograms) and identify abnormal findings that require further testing or consultation.
Order appropriate monitoring and correctly interpret monitor data.
Engage consultants and support staff (such as subspecialty physicians and social workers) efficiently and appropriately.
Use the ALTE admission as an opportunity to educate the family/caregiver on proper sleep positioning and risk factors for SIDS.
Impart basic resuscitation skills to the family/caregiver, using a teach‐back method.
Coordinate care with the primary care provider and arrange an appropriate transition plan for hospital discharge.
Attitudes
Pediatric hospitalists should be able to:
Communicate effectively with the family/caregiver, and healthcare providers regarding findings and care plans.
Ensure a safe and supportive atmosphere for the patient and family during the period of observation and evaluation of a child admitted following an ALTE.
Counsel the family/caregiver on the valid use of home monitors in a limited population, noting the features which support or refute use of a home monitor for their child.
Realize the impact of an ALTE on the family/caregiver and the implications for discharge planning and follow‐up.
Role model professional behavior when addressing issues related to potential social concerns and child abuse evaluation.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Lead, coordinate or participate in multidisciplinary initiatives to develop and implement evidence‐based clinical guidelines to improve quality of care for infants with ALTE.
Advocate for preventive education regarding sudden infant death syndrome in the hospital system and community.
Introduction
Apparent Life‐Threatening Event (ALTE) is defined by the NIH Consensus Development Conference on Infantile Apnea and Home Monitoring as an episode that is frightening to the observer and that is characterized by some combination of apnea (central or occasionally obstructive), color change (usually cyanotic or pallid but occasionally erythematous or plethoric), marked change in muscle tone (usually marked limpness), choking, or gagging. Because ALTE is a description of symptoms rather than a diagnosis, epidemiologic data is imprecise. It is estimated that 1‐3% of infants will have an episode that can be described as an ALTE and that most of these infants present before 2 months of life. Pediatric hospitalists can provide a valuable service to the family/caregiver by reconciling the potentially life threatening nature of ALTE with an infant who often appears normal on physical examination. Pediatric hospitalists should approach the broad differential diagnosis in a logical, systematic manner.
Knowledge
Pediatric hospitalists should be able to:
Describe the differential diagnosis of ALTE (such as gastroesophageal reflux disease, seizure, apnea of prematurity, infection [sepsis, meningitis, pertussis, bronchiolitis], toxin, breath‐holding spell, cardiac arrhythmia, obstructive sleep apnea, inborn errors of metabolism, central hypoventilation syndrome, hydrocephalus, child abuse, Munchausen's Syndrome by Proxy, and others) and the key historical or physical findings specifically associated with each diagnosis.
Provide indications for admission to the hospital and determine the appropriate level of care required.
Describe the goals of hospitalization including stabilization, diagnosis, treatment, reassurance, and education.
Compare and contrast Sudden Infant Death Syndrome (SIDS) versus ALTE,
Discuss current hypotheses regarding the etiology of SIDS and relate this to the spectrum of disorders that may cause ALTE.
Describe a basic approach toward the work‐up for ALTE and list the factors that may warrant an increased level of laboratory, radiographic, or other testing.
Summarize the literature on the impact of home monitors on morbidity and mortality and identify the benefits and limitations of home monitoring.
Skills
Pediatric hospitalists should be able to:
Resuscitate and stabilize an infant with ALTE who presents in an unstable state.
Obtain an accurate patient history and perform a thorough physical examination eliciting features to narrow the differential diagnosis of ALTE.
Critically assess the level of evidence and risk/benefit ratio for the diagnostic work‐up and management plan.
Interpret basic tests (such as laboratory tests, chest x‐rays, and electrocardiograms) and identify abnormal findings that require further testing or consultation.
Order appropriate monitoring and correctly interpret monitor data.
Engage consultants and support staff (such as subspecialty physicians and social workers) efficiently and appropriately.
Use the ALTE admission as an opportunity to educate the family/caregiver on proper sleep positioning and risk factors for SIDS.
Impart basic resuscitation skills to the family/caregiver, using a teach‐back method.
Coordinate care with the primary care provider and arrange an appropriate transition plan for hospital discharge.
Attitudes
Pediatric hospitalists should be able to:
Communicate effectively with the family/caregiver, and healthcare providers regarding findings and care plans.
Ensure a safe and supportive atmosphere for the patient and family during the period of observation and evaluation of a child admitted following an ALTE.
Counsel the family/caregiver on the valid use of home monitors in a limited population, noting the features which support or refute use of a home monitor for their child.
Realize the impact of an ALTE on the family/caregiver and the implications for discharge planning and follow‐up.
Role model professional behavior when addressing issues related to potential social concerns and child abuse evaluation.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Lead, coordinate or participate in multidisciplinary initiatives to develop and implement evidence‐based clinical guidelines to improve quality of care for infants with ALTE.
Advocate for preventive education regarding sudden infant death syndrome in the hospital system and community.
Copyright © 2010 Society of Hospital Medicine
Hospice and palliative care
Introduction
Pediatric palliative and/or hospice care are increasingly important components of the continuum of care for hospitalized children. As both a philosophy and an organized method for delivering care, these approaches to care focus on the relief of physical, psychosocial, and spiritual suffering experienced by infants, children and adolescents and the family/caregiver who face a life‐threatening condition. The guiding philosophy includes comfort and quality of life, while at the same time sustaining hope despite the likelihood of death. The goals of this type of care include enhancing choices, relieving pain and suffering and ensuring the best quality of care for the child and family/caregiver during the stages of living, dying and grief and bereavement. Care may be provided at home, in an inpatient hospice setting or within a traditional hospital setting. Palliative care services are most easily accessible in the traditional intensive care and hospital settings. Resources for treatment of dying children outside of these settings may be quite limited and vary by geographic location. Pediatric hospitalists therefore are often in the best position to provide both leadership and clinical roles for children requiring these services. Pediatric hospitalists should be able to access available palliative and hospice services and must be comfortable managing ethical dilemmas encountered in the inpatient setting related to care of the dying patient.
Knowledge
Pediatric hospitalists should be able to:
Define the terms palliative and hospice care and describe the similarities and differences between them.
Give examples of children who may be appropriate for hospice and palliative care services.
Describe why pediatric hospice and palliative care are optimally provided by an interdisciplinary team consisting of a pediatrician, pediatric nurse, social worker, chaplain, home health aide, and others.
Compare and contrast multidisciplinary with interdisciplinary team dynamics.
Describe why the decision related to forgoing potentially life‐sustaining treatments or the withdrawal of life support often are best made before a child becomes critically ill.
Discuss the elements of a treatment plan for relief of suffering, including appropriate consultations (such as palliative care, pain service, physiatrists, and others) and therapies (such as complementary medicine, pain medications, and others).
Explain how elements of palliative treatment and curative treatment may simultaneously occur during the course of treatment of a child's life limiting illness.
Identify local, regional, and national resources for pediatric palliative and hospice care that are accessible to patients, the family/caregiver, and healthcare providers.
Describe the role and composition of a hospital Ethics Committee as it relates to patient and family/caregiver decisions regarding end‐of‐life decisions.
Describe the processes involved in writing Allow Natural Death (AND) orders, pronouncing a person dead, completing a death certificate, discussing autopsy and donor mandates and options, and accessing immediate support for family/caregiver and staff.
Skills
Pediatric hospitalists should be able to:
Proactively identify opportunities for appropriate referral to and utilization of hospice and palliative care services.
Communicate bad news effectively and provide opportunities for patients and the family/caregiver to be introduced to palliative care or hospice services when appropriate.
Manage ethical dilemmas encountered in the inpatient setting related to care of the dying patient.
Integrate cultural issues in discussions and management of end of life issues.
Effectively adapt communication methods to varying age and developmental stages to assure understanding of chronic illness, death and dying.
Recognize and manage pain and other common symptoms causing distress for patients and the family/caregiver at the end of life.
Correctly prescribe medication and non‐medication therapies in collaboration with appropriate consultants.
Attitudes
Pediatric hospitalists should be able to:
Create awareness for the importance of pediatric palliative and hospice care.
Demonstrate awareness and acceptance of palliative care approaches, which may include alternative and/or complementary medical therapies.
Role model ethical behavior at all times.
Identify personal attitudes toward end of life care from a physical, psychosocial and spiritual perspective.
Recognize when personal perspective and bias may influence care for dying patients.
Identify gaps in personal knowledge, skills and attitudes regarding palliative care and utilize opportunities for professional education to address them.
Collaborate with the interdisciplinary team, subspecialists and the primary care provider to ensure coordinated longitudinal care for children receiving palliative or hospice services.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Engage in organizational efforts to provide pediatric hospice and palliative care education for interdisciplinary teams.
Create or help sustain a pediatric perspective for hospital Ethics Committees.
Collaborate with hospital administration and community partners to ensure efficient access to appropriate consultants necessary for success of these programs for children.
Advocate for development of pediatric hospice and palliative care resources in their hospital and their community.
Introduction
Pediatric palliative and/or hospice care are increasingly important components of the continuum of care for hospitalized children. As both a philosophy and an organized method for delivering care, these approaches to care focus on the relief of physical, psychosocial, and spiritual suffering experienced by infants, children and adolescents and the family/caregiver who face a life‐threatening condition. The guiding philosophy includes comfort and quality of life, while at the same time sustaining hope despite the likelihood of death. The goals of this type of care include enhancing choices, relieving pain and suffering and ensuring the best quality of care for the child and family/caregiver during the stages of living, dying and grief and bereavement. Care may be provided at home, in an inpatient hospice setting or within a traditional hospital setting. Palliative care services are most easily accessible in the traditional intensive care and hospital settings. Resources for treatment of dying children outside of these settings may be quite limited and vary by geographic location. Pediatric hospitalists therefore are often in the best position to provide both leadership and clinical roles for children requiring these services. Pediatric hospitalists should be able to access available palliative and hospice services and must be comfortable managing ethical dilemmas encountered in the inpatient setting related to care of the dying patient.
Knowledge
Pediatric hospitalists should be able to:
Define the terms palliative and hospice care and describe the similarities and differences between them.
Give examples of children who may be appropriate for hospice and palliative care services.
Describe why pediatric hospice and palliative care are optimally provided by an interdisciplinary team consisting of a pediatrician, pediatric nurse, social worker, chaplain, home health aide, and others.
Compare and contrast multidisciplinary with interdisciplinary team dynamics.
Describe why the decision related to forgoing potentially life‐sustaining treatments or the withdrawal of life support often are best made before a child becomes critically ill.
Discuss the elements of a treatment plan for relief of suffering, including appropriate consultations (such as palliative care, pain service, physiatrists, and others) and therapies (such as complementary medicine, pain medications, and others).
Explain how elements of palliative treatment and curative treatment may simultaneously occur during the course of treatment of a child's life limiting illness.
Identify local, regional, and national resources for pediatric palliative and hospice care that are accessible to patients, the family/caregiver, and healthcare providers.
Describe the role and composition of a hospital Ethics Committee as it relates to patient and family/caregiver decisions regarding end‐of‐life decisions.
Describe the processes involved in writing Allow Natural Death (AND) orders, pronouncing a person dead, completing a death certificate, discussing autopsy and donor mandates and options, and accessing immediate support for family/caregiver and staff.
Skills
Pediatric hospitalists should be able to:
Proactively identify opportunities for appropriate referral to and utilization of hospice and palliative care services.
Communicate bad news effectively and provide opportunities for patients and the family/caregiver to be introduced to palliative care or hospice services when appropriate.
Manage ethical dilemmas encountered in the inpatient setting related to care of the dying patient.
Integrate cultural issues in discussions and management of end of life issues.
Effectively adapt communication methods to varying age and developmental stages to assure understanding of chronic illness, death and dying.
Recognize and manage pain and other common symptoms causing distress for patients and the family/caregiver at the end of life.
Correctly prescribe medication and non‐medication therapies in collaboration with appropriate consultants.
Attitudes
Pediatric hospitalists should be able to:
Create awareness for the importance of pediatric palliative and hospice care.
Demonstrate awareness and acceptance of palliative care approaches, which may include alternative and/or complementary medical therapies.
Role model ethical behavior at all times.
Identify personal attitudes toward end of life care from a physical, psychosocial and spiritual perspective.
Recognize when personal perspective and bias may influence care for dying patients.
Identify gaps in personal knowledge, skills and attitudes regarding palliative care and utilize opportunities for professional education to address them.
Collaborate with the interdisciplinary team, subspecialists and the primary care provider to ensure coordinated longitudinal care for children receiving palliative or hospice services.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Engage in organizational efforts to provide pediatric hospice and palliative care education for interdisciplinary teams.
Create or help sustain a pediatric perspective for hospital Ethics Committees.
Collaborate with hospital administration and community partners to ensure efficient access to appropriate consultants necessary for success of these programs for children.
Advocate for development of pediatric hospice and palliative care resources in their hospital and their community.
Introduction
Pediatric palliative and/or hospice care are increasingly important components of the continuum of care for hospitalized children. As both a philosophy and an organized method for delivering care, these approaches to care focus on the relief of physical, psychosocial, and spiritual suffering experienced by infants, children and adolescents and the family/caregiver who face a life‐threatening condition. The guiding philosophy includes comfort and quality of life, while at the same time sustaining hope despite the likelihood of death. The goals of this type of care include enhancing choices, relieving pain and suffering and ensuring the best quality of care for the child and family/caregiver during the stages of living, dying and grief and bereavement. Care may be provided at home, in an inpatient hospice setting or within a traditional hospital setting. Palliative care services are most easily accessible in the traditional intensive care and hospital settings. Resources for treatment of dying children outside of these settings may be quite limited and vary by geographic location. Pediatric hospitalists therefore are often in the best position to provide both leadership and clinical roles for children requiring these services. Pediatric hospitalists should be able to access available palliative and hospice services and must be comfortable managing ethical dilemmas encountered in the inpatient setting related to care of the dying patient.
Knowledge
Pediatric hospitalists should be able to:
Define the terms palliative and hospice care and describe the similarities and differences between them.
Give examples of children who may be appropriate for hospice and palliative care services.
Describe why pediatric hospice and palliative care are optimally provided by an interdisciplinary team consisting of a pediatrician, pediatric nurse, social worker, chaplain, home health aide, and others.
Compare and contrast multidisciplinary with interdisciplinary team dynamics.
Describe why the decision related to forgoing potentially life‐sustaining treatments or the withdrawal of life support often are best made before a child becomes critically ill.
Discuss the elements of a treatment plan for relief of suffering, including appropriate consultations (such as palliative care, pain service, physiatrists, and others) and therapies (such as complementary medicine, pain medications, and others).
Explain how elements of palliative treatment and curative treatment may simultaneously occur during the course of treatment of a child's life limiting illness.
Identify local, regional, and national resources for pediatric palliative and hospice care that are accessible to patients, the family/caregiver, and healthcare providers.
Describe the role and composition of a hospital Ethics Committee as it relates to patient and family/caregiver decisions regarding end‐of‐life decisions.
Describe the processes involved in writing Allow Natural Death (AND) orders, pronouncing a person dead, completing a death certificate, discussing autopsy and donor mandates and options, and accessing immediate support for family/caregiver and staff.
Skills
Pediatric hospitalists should be able to:
Proactively identify opportunities for appropriate referral to and utilization of hospice and palliative care services.
Communicate bad news effectively and provide opportunities for patients and the family/caregiver to be introduced to palliative care or hospice services when appropriate.
Manage ethical dilemmas encountered in the inpatient setting related to care of the dying patient.
Integrate cultural issues in discussions and management of end of life issues.
Effectively adapt communication methods to varying age and developmental stages to assure understanding of chronic illness, death and dying.
Recognize and manage pain and other common symptoms causing distress for patients and the family/caregiver at the end of life.
Correctly prescribe medication and non‐medication therapies in collaboration with appropriate consultants.
Attitudes
Pediatric hospitalists should be able to:
Create awareness for the importance of pediatric palliative and hospice care.
Demonstrate awareness and acceptance of palliative care approaches, which may include alternative and/or complementary medical therapies.
Role model ethical behavior at all times.
Identify personal attitudes toward end of life care from a physical, psychosocial and spiritual perspective.
Recognize when personal perspective and bias may influence care for dying patients.
Identify gaps in personal knowledge, skills and attitudes regarding palliative care and utilize opportunities for professional education to address them.
Collaborate with the interdisciplinary team, subspecialists and the primary care provider to ensure coordinated longitudinal care for children receiving palliative or hospice services.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Engage in organizational efforts to provide pediatric hospice and palliative care education for interdisciplinary teams.
Create or help sustain a pediatric perspective for hospital Ethics Committees.
Collaborate with hospital administration and community partners to ensure efficient access to appropriate consultants necessary for success of these programs for children.
Advocate for development of pediatric hospice and palliative care resources in their hospital and their community.
Copyright © 2010 Society of Hospital Medicine
Pneumonia
Introduction
Lower respiratory tract infections cause substantial morbidity and mortality in the pediatric population. Worldwide, an estimated 4 million children die from pneumonia each year, with higher mortality rates seen in developing countries. In the United States, pneumonia accounts for up to 1 in 5 pediatric hospitalizations. Pneumonia is commonly caused by a viral infection, especially in children less than 2 years of age. Despite high rates of viral disease in young children, bacterial co‐infection is common. Non‐viral etiologies for pneumonia differ based upon age and underlying risk factors resulting in the need to tailor antimicrobials appropriately. Surgical intervention may be required when pneumonia is complicated by pleural effusion or abscess. Pediatric hospitalists are the attending of record, coordinate subspecialty care when necessary, and are often in the best position to lead quality improvement initiatives to optimize pneumonia care.
Knowledge
Pediatric hospitalists should be able to:
Describe the key features of the history and physical examination that support or refute the diagnosis of pneumonia.
Discuss the variations in clinical presentation that may accompany chronic health conditions of childhood, such as cystic fibrosis, chronic lung disease, congenital heart disease, immunodeficiency, and others.
Review alternate diagnoses which may mimic the presentation of pneumonia including anatomic defects, systemic diseases, heart failure, and others.
Provide indications for hospital admission and determine the appropriate level of care.
List common bacterial, atypical bacterial, and viral organisms causing pneumonia and state how these differ based on age.
Name other causes of infectious and non‐infectious pneumonias such as lipoid, inhalation pneumonitis, aspiration, and others.
Discuss the influence of national immunization practices and antimicrobial use on predominant organisms and resistance patterns.
Describe local resistance patterns for predominant infectious organisms.
Discuss the benefits and limitations of radiography and laboratory evaluation in the diagnosis of pneumonia.
Describe common complications seen with pneumonia and list co‐morbidities or infectious etiologies associated with higher risk for each.
Describe the indications and options for surgical intervention in patients with complicated pneumonia.
Summarize goals for hospital discharge attending to symptoms, oxygenation saturation, hydration, and family/caregiver needs, and outpatient management plans.
Skills
Pediatric hospitalists should be able to:
Correctly diagnose pneumonia by efficiently performing an accurate history and physical examination, determining if key features of the disease are present.
Order appropriate laboratory and radiographic tests to guide treatment and ensure proper isolation.
Direct an evidence‐based treatment plan, including cardio‐respiratory monitoring, oxygen supplementation, and appropriately selected antibiotic therapy as indicated.
Accurately interpret chest radiographs and distinguishing between consolidation, effusion, mass, and other presentations.
Perform careful reassessments daily and as needed, note changes in clinical status, and respond with appropriate actions.
Correctly determine when consultation with a surgeon or other subspecialist or a transfer to a higher level of care is indicated.
Identify patients requiring extended evaluation for underlying anatomic or systemic disease.
Coordinate discharge efficiently and effectively with patients, family/caregiver, subspecialists, and the primary care provider including home care needs and follow‐up as appropriate.
Create a comprehensive discharge plan including home care as appropriate.
Attitudes
Pediatric hospitalists should be able to:
Role model and advocate for strict adherence to infection control practices and educate the family/caregiver regarding measures such as handwashing to reduce the spread of infection.
Communicate effectively with patients, the family/caregiver and healthcare providers regarding findings and care plans.
Collaborate with subspecialists to render safe and efficient treatment.
Realize the importance of antimicrobial stewardship and consistently modify prescribing practice to reflect best practices attending to local resistance patterns.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Work with hospital, community, and infectious disease experts to develop and sustain local communications regarding resistance pattern changes.
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 pneumonia.
Introduction
Lower respiratory tract infections cause substantial morbidity and mortality in the pediatric population. Worldwide, an estimated 4 million children die from pneumonia each year, with higher mortality rates seen in developing countries. In the United States, pneumonia accounts for up to 1 in 5 pediatric hospitalizations. Pneumonia is commonly caused by a viral infection, especially in children less than 2 years of age. Despite high rates of viral disease in young children, bacterial co‐infection is common. Non‐viral etiologies for pneumonia differ based upon age and underlying risk factors resulting in the need to tailor antimicrobials appropriately. Surgical intervention may be required when pneumonia is complicated by pleural effusion or abscess. Pediatric hospitalists are the attending of record, coordinate subspecialty care when necessary, and are often in the best position to lead quality improvement initiatives to optimize pneumonia care.
Knowledge
Pediatric hospitalists should be able to:
Describe the key features of the history and physical examination that support or refute the diagnosis of pneumonia.
Discuss the variations in clinical presentation that may accompany chronic health conditions of childhood, such as cystic fibrosis, chronic lung disease, congenital heart disease, immunodeficiency, and others.
Review alternate diagnoses which may mimic the presentation of pneumonia including anatomic defects, systemic diseases, heart failure, and others.
Provide indications for hospital admission and determine the appropriate level of care.
List common bacterial, atypical bacterial, and viral organisms causing pneumonia and state how these differ based on age.
Name other causes of infectious and non‐infectious pneumonias such as lipoid, inhalation pneumonitis, aspiration, and others.
Discuss the influence of national immunization practices and antimicrobial use on predominant organisms and resistance patterns.
Describe local resistance patterns for predominant infectious organisms.
Discuss the benefits and limitations of radiography and laboratory evaluation in the diagnosis of pneumonia.
Describe common complications seen with pneumonia and list co‐morbidities or infectious etiologies associated with higher risk for each.
Describe the indications and options for surgical intervention in patients with complicated pneumonia.
Summarize goals for hospital discharge attending to symptoms, oxygenation saturation, hydration, and family/caregiver needs, and outpatient management plans.
Skills
Pediatric hospitalists should be able to:
Correctly diagnose pneumonia by efficiently performing an accurate history and physical examination, determining if key features of the disease are present.
Order appropriate laboratory and radiographic tests to guide treatment and ensure proper isolation.
Direct an evidence‐based treatment plan, including cardio‐respiratory monitoring, oxygen supplementation, and appropriately selected antibiotic therapy as indicated.
Accurately interpret chest radiographs and distinguishing between consolidation, effusion, mass, and other presentations.
Perform careful reassessments daily and as needed, note changes in clinical status, and respond with appropriate actions.
Correctly determine when consultation with a surgeon or other subspecialist or a transfer to a higher level of care is indicated.
Identify patients requiring extended evaluation for underlying anatomic or systemic disease.
Coordinate discharge efficiently and effectively with patients, family/caregiver, subspecialists, and the primary care provider including home care needs and follow‐up as appropriate.
Create a comprehensive discharge plan including home care as appropriate.
Attitudes
Pediatric hospitalists should be able to:
Role model and advocate for strict adherence to infection control practices and educate the family/caregiver regarding measures such as handwashing to reduce the spread of infection.
Communicate effectively with patients, the family/caregiver and healthcare providers regarding findings and care plans.
Collaborate with subspecialists to render safe and efficient treatment.
Realize the importance of antimicrobial stewardship and consistently modify prescribing practice to reflect best practices attending to local resistance patterns.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Work with hospital, community, and infectious disease experts to develop and sustain local communications regarding resistance pattern changes.
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 pneumonia.
Introduction
Lower respiratory tract infections cause substantial morbidity and mortality in the pediatric population. Worldwide, an estimated 4 million children die from pneumonia each year, with higher mortality rates seen in developing countries. In the United States, pneumonia accounts for up to 1 in 5 pediatric hospitalizations. Pneumonia is commonly caused by a viral infection, especially in children less than 2 years of age. Despite high rates of viral disease in young children, bacterial co‐infection is common. Non‐viral etiologies for pneumonia differ based upon age and underlying risk factors resulting in the need to tailor antimicrobials appropriately. Surgical intervention may be required when pneumonia is complicated by pleural effusion or abscess. Pediatric hospitalists are the attending of record, coordinate subspecialty care when necessary, and are often in the best position to lead quality improvement initiatives to optimize pneumonia care.
Knowledge
Pediatric hospitalists should be able to:
Describe the key features of the history and physical examination that support or refute the diagnosis of pneumonia.
Discuss the variations in clinical presentation that may accompany chronic health conditions of childhood, such as cystic fibrosis, chronic lung disease, congenital heart disease, immunodeficiency, and others.
Review alternate diagnoses which may mimic the presentation of pneumonia including anatomic defects, systemic diseases, heart failure, and others.
Provide indications for hospital admission and determine the appropriate level of care.
List common bacterial, atypical bacterial, and viral organisms causing pneumonia and state how these differ based on age.
Name other causes of infectious and non‐infectious pneumonias such as lipoid, inhalation pneumonitis, aspiration, and others.
Discuss the influence of national immunization practices and antimicrobial use on predominant organisms and resistance patterns.
Describe local resistance patterns for predominant infectious organisms.
Discuss the benefits and limitations of radiography and laboratory evaluation in the diagnosis of pneumonia.
Describe common complications seen with pneumonia and list co‐morbidities or infectious etiologies associated with higher risk for each.
Describe the indications and options for surgical intervention in patients with complicated pneumonia.
Summarize goals for hospital discharge attending to symptoms, oxygenation saturation, hydration, and family/caregiver needs, and outpatient management plans.
Skills
Pediatric hospitalists should be able to:
Correctly diagnose pneumonia by efficiently performing an accurate history and physical examination, determining if key features of the disease are present.
Order appropriate laboratory and radiographic tests to guide treatment and ensure proper isolation.
Direct an evidence‐based treatment plan, including cardio‐respiratory monitoring, oxygen supplementation, and appropriately selected antibiotic therapy as indicated.
Accurately interpret chest radiographs and distinguishing between consolidation, effusion, mass, and other presentations.
Perform careful reassessments daily and as needed, note changes in clinical status, and respond with appropriate actions.
Correctly determine when consultation with a surgeon or other subspecialist or a transfer to a higher level of care is indicated.
Identify patients requiring extended evaluation for underlying anatomic or systemic disease.
Coordinate discharge efficiently and effectively with patients, family/caregiver, subspecialists, and the primary care provider including home care needs and follow‐up as appropriate.
Create a comprehensive discharge plan including home care as appropriate.
Attitudes
Pediatric hospitalists should be able to:
Role model and advocate for strict adherence to infection control practices and educate the family/caregiver regarding measures such as handwashing to reduce the spread of infection.
Communicate effectively with patients, the family/caregiver and healthcare providers regarding findings and care plans.
Collaborate with subspecialists to render safe and efficient treatment.
Realize the importance of antimicrobial stewardship and consistently modify prescribing practice to reflect best practices attending to local resistance patterns.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Work with hospital, community, and infectious disease experts to develop and sustain local communications regarding resistance pattern changes.
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 pneumonia.
Copyright © 2010 Society of Hospital Medicine
Neonatal fever
Introduction
Fever in a neonate ( 28 days of age) is defined as a rectal temperature above 38C, and may occur in 20% of neonates admitted to the hospital. Approximately 10% of neonates with fever have a serious bacterial infection. However, some neonates with serious bacterial infection present with hypothermia, usually defined as a rectal temperature below 36.5C. Infection in neonates often occurs as a result of both a nave immune system and exposure to pathogenic bacteria during delivery, although pathogens acquired in the postnatal period are also possible. Serious bacterial infections in neonates are most predominant in the renal, pulmonary, central nervous, and blood systems. The prevalence of each varies by age and gender. Neonates may also develop serious illness when be exposed to viral infections, especially herpes simplex virus (HSV). In febrile neonates without a clear source of illness, distinguishing between those with self‐limiting versus life‐threatening infection is challenging. Well‐appearing infants over 28 days of age may be managed without hospitalization in selected circumstances. However, more conservative inpatient evaluation, monitoring, and management of neonates younger than 28 days of age with abnormal temperature is currently standard. Pediatric hospitalists should render evidence‐based care for these neonates.
Knowledge
Pediatric hospitalists should be able to:
Define hypothermia and hyperthermia in neonates and describe how to correctly obtain a temperature using a variety of modalities.
Discuss the basic mechanisms of temperature regulation in neonates.
Compare and contrast basic immune maturity differences in neonates versus older infants.
Delineate the elements of the history (such as birth history, perinatal exposures, maternal infections and others) and physical examination (such as skin lesions, neurobehavioral exam and others) that aid in determining a diagnosis.
Describe the differential diagnosis of neonatal sepsis and discuss how other potentially serious illnesses, such as inborn error of metabolism, may mimic its presentation.
List the organisms which are responsible for serious bacterial infection in neonates, including the types of infections they cause and the relative prevalence of each.
Review the approach toward evaluation in the preterm infant, attending to extent of prematurity and neonatal intensive care course.
Compare and contrast the signs and symptoms more suggestive of bacterial versus viral illnesses.
Distinguish between the current standard laboratory evaluation for neonates with that for older infants, using current literature for reference.
Describe the role of viral testing, including interpretation of frequencies of disease, co‐infections with bacterial disease, local turnaround time, and predictive value of testing.
Summarize the approach to empiric antimicrobial therapy and give examples of situations warranting expanded antimicrobial coverage.
Skills
Pediatric hospitalists should be able to:
Obtain a complete history, including pregnancy and birth history, with particular attention paid to prenatal laboratory screening and the use of antibiotic prophylaxis prior to delivery.
Perform a comprehensive physical examination, with attention paid to signs and symptoms that may indicate a source of infection or signify severe illness.
Accurately perform, supervise, or direct basic procedures to obtain specimens, including venipuncture, bladder catheterization, lumbar puncture, and placement of intravenous access.
Interpret the results of laboratory evaluations efficiently and adjust the differential diagnosis and plan of care accordingly.
Select appropriate empiric antimicrobial coverage in an evidence‐based manner.
Perform careful reassessments daily and as needed, note changes in clinical status and respond with appropriate actions.
Efficiently render care by creating a discharge plan which can be expediently activated when appropriate.
Attitudes
Pediatric hospitalists should be able to:
Elicit and allay the concerns of the family/caregiver, educating them regarding the importance of a thorough evaluation for the source of infection and the need for empiric antimicrobial therapy.
Communicate effectively with the family/caregiver and healthcare providers regarding findings and care plans.
Educate the family/caregiver about the final diagnosis, clearly explaining the value of negative test results if applicable.
Recognize the significance of performing invasive procedures on a neonate from the family/caregiver perspective, maintaining empathy when discussing the risks and benefits of necessary procedures.
Assure an effective and safe discharge by communicating and coordinating effectively with the primary care provider.
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 neonates with fever.
Lead, coordinate or participate in efforts to develop institutional guidelines for the judicious use of antimicrobials in neonates with fever.
Introduction
Fever in a neonate ( 28 days of age) is defined as a rectal temperature above 38C, and may occur in 20% of neonates admitted to the hospital. Approximately 10% of neonates with fever have a serious bacterial infection. However, some neonates with serious bacterial infection present with hypothermia, usually defined as a rectal temperature below 36.5C. Infection in neonates often occurs as a result of both a nave immune system and exposure to pathogenic bacteria during delivery, although pathogens acquired in the postnatal period are also possible. Serious bacterial infections in neonates are most predominant in the renal, pulmonary, central nervous, and blood systems. The prevalence of each varies by age and gender. Neonates may also develop serious illness when be exposed to viral infections, especially herpes simplex virus (HSV). In febrile neonates without a clear source of illness, distinguishing between those with self‐limiting versus life‐threatening infection is challenging. Well‐appearing infants over 28 days of age may be managed without hospitalization in selected circumstances. However, more conservative inpatient evaluation, monitoring, and management of neonates younger than 28 days of age with abnormal temperature is currently standard. Pediatric hospitalists should render evidence‐based care for these neonates.
Knowledge
Pediatric hospitalists should be able to:
Define hypothermia and hyperthermia in neonates and describe how to correctly obtain a temperature using a variety of modalities.
Discuss the basic mechanisms of temperature regulation in neonates.
Compare and contrast basic immune maturity differences in neonates versus older infants.
Delineate the elements of the history (such as birth history, perinatal exposures, maternal infections and others) and physical examination (such as skin lesions, neurobehavioral exam and others) that aid in determining a diagnosis.
Describe the differential diagnosis of neonatal sepsis and discuss how other potentially serious illnesses, such as inborn error of metabolism, may mimic its presentation.
List the organisms which are responsible for serious bacterial infection in neonates, including the types of infections they cause and the relative prevalence of each.
Review the approach toward evaluation in the preterm infant, attending to extent of prematurity and neonatal intensive care course.
Compare and contrast the signs and symptoms more suggestive of bacterial versus viral illnesses.
Distinguish between the current standard laboratory evaluation for neonates with that for older infants, using current literature for reference.
Describe the role of viral testing, including interpretation of frequencies of disease, co‐infections with bacterial disease, local turnaround time, and predictive value of testing.
Summarize the approach to empiric antimicrobial therapy and give examples of situations warranting expanded antimicrobial coverage.
Skills
Pediatric hospitalists should be able to:
Obtain a complete history, including pregnancy and birth history, with particular attention paid to prenatal laboratory screening and the use of antibiotic prophylaxis prior to delivery.
Perform a comprehensive physical examination, with attention paid to signs and symptoms that may indicate a source of infection or signify severe illness.
Accurately perform, supervise, or direct basic procedures to obtain specimens, including venipuncture, bladder catheterization, lumbar puncture, and placement of intravenous access.
Interpret the results of laboratory evaluations efficiently and adjust the differential diagnosis and plan of care accordingly.
Select appropriate empiric antimicrobial coverage in an evidence‐based manner.
Perform careful reassessments daily and as needed, note changes in clinical status and respond with appropriate actions.
Efficiently render care by creating a discharge plan which can be expediently activated when appropriate.
Attitudes
Pediatric hospitalists should be able to:
Elicit and allay the concerns of the family/caregiver, educating them regarding the importance of a thorough evaluation for the source of infection and the need for empiric antimicrobial therapy.
Communicate effectively with the family/caregiver and healthcare providers regarding findings and care plans.
Educate the family/caregiver about the final diagnosis, clearly explaining the value of negative test results if applicable.
Recognize the significance of performing invasive procedures on a neonate from the family/caregiver perspective, maintaining empathy when discussing the risks and benefits of necessary procedures.
Assure an effective and safe discharge by communicating and coordinating effectively with the primary care provider.
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 neonates with fever.
Lead, coordinate or participate in efforts to develop institutional guidelines for the judicious use of antimicrobials in neonates with fever.
Introduction
Fever in a neonate ( 28 days of age) is defined as a rectal temperature above 38C, and may occur in 20% of neonates admitted to the hospital. Approximately 10% of neonates with fever have a serious bacterial infection. However, some neonates with serious bacterial infection present with hypothermia, usually defined as a rectal temperature below 36.5C. Infection in neonates often occurs as a result of both a nave immune system and exposure to pathogenic bacteria during delivery, although pathogens acquired in the postnatal period are also possible. Serious bacterial infections in neonates are most predominant in the renal, pulmonary, central nervous, and blood systems. The prevalence of each varies by age and gender. Neonates may also develop serious illness when be exposed to viral infections, especially herpes simplex virus (HSV). In febrile neonates without a clear source of illness, distinguishing between those with self‐limiting versus life‐threatening infection is challenging. Well‐appearing infants over 28 days of age may be managed without hospitalization in selected circumstances. However, more conservative inpatient evaluation, monitoring, and management of neonates younger than 28 days of age with abnormal temperature is currently standard. Pediatric hospitalists should render evidence‐based care for these neonates.
Knowledge
Pediatric hospitalists should be able to:
Define hypothermia and hyperthermia in neonates and describe how to correctly obtain a temperature using a variety of modalities.
Discuss the basic mechanisms of temperature regulation in neonates.
Compare and contrast basic immune maturity differences in neonates versus older infants.
Delineate the elements of the history (such as birth history, perinatal exposures, maternal infections and others) and physical examination (such as skin lesions, neurobehavioral exam and others) that aid in determining a diagnosis.
Describe the differential diagnosis of neonatal sepsis and discuss how other potentially serious illnesses, such as inborn error of metabolism, may mimic its presentation.
List the organisms which are responsible for serious bacterial infection in neonates, including the types of infections they cause and the relative prevalence of each.
Review the approach toward evaluation in the preterm infant, attending to extent of prematurity and neonatal intensive care course.
Compare and contrast the signs and symptoms more suggestive of bacterial versus viral illnesses.
Distinguish between the current standard laboratory evaluation for neonates with that for older infants, using current literature for reference.
Describe the role of viral testing, including interpretation of frequencies of disease, co‐infections with bacterial disease, local turnaround time, and predictive value of testing.
Summarize the approach to empiric antimicrobial therapy and give examples of situations warranting expanded antimicrobial coverage.
Skills
Pediatric hospitalists should be able to:
Obtain a complete history, including pregnancy and birth history, with particular attention paid to prenatal laboratory screening and the use of antibiotic prophylaxis prior to delivery.
Perform a comprehensive physical examination, with attention paid to signs and symptoms that may indicate a source of infection or signify severe illness.
Accurately perform, supervise, or direct basic procedures to obtain specimens, including venipuncture, bladder catheterization, lumbar puncture, and placement of intravenous access.
Interpret the results of laboratory evaluations efficiently and adjust the differential diagnosis and plan of care accordingly.
Select appropriate empiric antimicrobial coverage in an evidence‐based manner.
Perform careful reassessments daily and as needed, note changes in clinical status and respond with appropriate actions.
Efficiently render care by creating a discharge plan which can be expediently activated when appropriate.
Attitudes
Pediatric hospitalists should be able to:
Elicit and allay the concerns of the family/caregiver, educating them regarding the importance of a thorough evaluation for the source of infection and the need for empiric antimicrobial therapy.
Communicate effectively with the family/caregiver and healthcare providers regarding findings and care plans.
Educate the family/caregiver about the final diagnosis, clearly explaining the value of negative test results if applicable.
Recognize the significance of performing invasive procedures on a neonate from the family/caregiver perspective, maintaining empathy when discussing the risks and benefits of necessary procedures.
Assure an effective and safe discharge by communicating and coordinating effectively with the primary care provider.
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 neonates with fever.
Lead, coordinate or participate in efforts to develop institutional guidelines for the judicious use of antimicrobials in neonates with fever.
Copyright © 2010 Society of Hospital Medicine
Transport of the critically ill child
Introduction
Pediatric inter‐facility transport first began in the 1970s when a two‐fold difference in mortality was first demonstrated between neonates cared for solely at a community hospital versus those transferred to a regional center. Today as medicine continues to make technological strides and therapeutic advances, community hospitals often find themselves ill equipped to provide acute care to ill and injured children. The growing trend toward centralized pediatric services further necessitates the transfer of children requiring subspecialty care to a regional facility. From these forces has come the advent of the pediatric critical care transport service. Like their neonatal counterparts, pediatric critical care transport teams are overseen in large part by pediatric intensivists or emergency medicine physicians. However, increasing demand for transport of non‐critically ill children, increasing presence of pediatric hospitalists, and increasing time constraints felt by pediatric intensivists is shifting the paradigm. Co‐direction of pediatric critical care transport services by intensivists and hospitalists is becoming more common. Transport systems vary from institution to institution, some having a dedicated in‐house pediatric critical care transport teams and others utilizing outside transport services. For transported patients, pediatric hospitalists may serve as referring or accepting attending physician, transport physician, or transport coordinator. Through each of these roles pediatric hospitalists fulfill an essential function in ensuring the safe and timely transport of ill children.
Knowledge
Pediatric hospitalists should be able to:
Compare and contrast advantages and disadvantages between transport modalities including non‐medical, Basic Life Support (BLS) ambulance, Advanced Life Support (ALS) ambulance, Critical Care Team (CCT) ambulance, and specialized Neonatal/Pediatric Critical Care Transport service (Table 1).
Discuss the role of the transport coordinator in effectively triaging to the proper facility, engaging subspecialty services, and determining safest modality of transport.
List the critical history and physical examination elements necessary (to give or obtain) to ensure a safe, effective, expeditious transport, attending to verbal, written, and electronic formats.
Explain how the selection of mode of transportation and team composition are influenced by patients' clinical status and transport logistics such as local traffic conditions, geographical distance, weather, and resources (internal and external) available at the time of the transport.
Describe the role of subspecialist and intensivist consultation in stabilization and management during transport and upon arrival to the destination facility.
Describe the knowledge base and skill set of non‐physician transport team members.
Review the use of standardized procedures on transport, including how they are used by non‐physician team members and the process for creation, approval, and oversight.
Discuss basic altitude physiology and describe how clinical conditions such as hypoxia can be impacted by changes in altitude.
Summarize the transport process, including communications, documentation, and team member roles attending to local context.
Discuss the role of the transport program in the local community, including services provided and outreach education.
| Transport Modality | Advantage | Disadvantage |
|---|---|---|
| Non‐medical (family/caregiver) | Low cost. | No ability to intervene as condition deteriorates. Transport may be delayed due to detours or misdirection. |
| BLS Ambulance or volunteer ambulance | Emergency Medical Technician escort. Some ability to intervene if condition deteriorates. | Little to no pediatric experience thus interventions are limited.Transport may be delayed due to variable ambulance availability. |
| ALS Ambulance or mid‐level transport | Paramedic escort; 1500‐2000 hours of medical training, including O2 administration, nebulized medications, ALS, and airway skills. Greater ability to triage and intervene if condition deteriorates. | Pediatric training not uniform. Paramedics primarily trained for extrication, intervention and rapid transport. |
| CCT ambulance | Critical care nurse team member. Allows for higher level of assessment and intervention. | Pediatric expertise is uncommon. |
| Specialized pediatric‐neonatal critical care transport service | 2‐3 member team composed of RN and RT (pediatric/neonatal critical care) and physician (hospital or emergency medicine, intensivist). Specialized pediatric assessment, monitoring, diagnostic, and interventional skills allows for high level pediatric care from initial referral. | High cost, limited resources. |
Skills
Pediatric hospitalists should be able to*:
(*As appropriate for pediatric hospitalists' role as referring or accepting attending physician, transport physician, or transport coordinator.)
Efficiently obtain or give critical clinical information placing particular emphasis on cardiac, pulmonary, and neurologic disease that could impact the transport process.
Provide recommendations regarding laboratory studies and imaging, as well as therapeutic options for referring facilities and physicians.
Effectively prepare the team to anticipate possible complications during any point in the transport, communicating all available clinical information and creating action plans for potential complications prior to transport.
Manage care during transport at a level and quality of care equivalent to that offered in the acute care hospital setting, limited only by medications and services not available during transport.
Demonstrate strong clinical abilities and expertise over a wide range of pediatric disease processes, making rapid assessments and initiating action plans on transport or at the referring or receiving facility.
Stabilize or remotely direct stabilization of patients at the referring facility and on transport, appropriately utilizing current Pediatric Advanced Life Support guidelines.
Obtain training and maintain skills for transport coordination, referral, and acceptance, including specialized transport issues such as flight physiology as appropriate.
Where pediatric hospitalists' roles include participation in neonatal transport, appropriately utilize current Neonatal Resuscitation Program and STABLE Program guidelines.
Recognize when to consult subspecialist, intensivist, or surgeon.
Accurately document actions and discussions in the medical record.
Attitudes
Pediatric hospitalists should be able to:
Respond promptly and courteously to all calls and requests for transport.
Participate in educational programs for transport team members and community referral sources.
Provide mentorship to junior hospitalists on all aspects of transport including clinical decision making, risk management, customer service, and operational issues.
Communicate effectively with patients and the family/caregiver regarding the need for and their role in the transport, as appropriate.
Establish and maintain good working relationships with referral sources and transport team members.
Recognize and manage patient care related conflicts among transport team members or referring facility in a prompt and judicious manner.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Work with hospital administration, transport team members, and specifically with the transport program manager, on the growth and development of the pediatric transport service and or policies.
Lead, coordinate or participate in ongoing educational opportunities to maintain the skill set of team members and transport coordinators.
Lead, coordinate or participate in the development and implementation of cost‐effective, safe, evidence‐based care pathways to standardize the management of common diagnoses for children transported between facilities.
Lead, coordinate or participate in establishing a multidisciplinary forum such as morbidity and mortality conference to regularly review cases with a goal of improving system‐wide processes and outcomes.
Introduction
Pediatric inter‐facility transport first began in the 1970s when a two‐fold difference in mortality was first demonstrated between neonates cared for solely at a community hospital versus those transferred to a regional center. Today as medicine continues to make technological strides and therapeutic advances, community hospitals often find themselves ill equipped to provide acute care to ill and injured children. The growing trend toward centralized pediatric services further necessitates the transfer of children requiring subspecialty care to a regional facility. From these forces has come the advent of the pediatric critical care transport service. Like their neonatal counterparts, pediatric critical care transport teams are overseen in large part by pediatric intensivists or emergency medicine physicians. However, increasing demand for transport of non‐critically ill children, increasing presence of pediatric hospitalists, and increasing time constraints felt by pediatric intensivists is shifting the paradigm. Co‐direction of pediatric critical care transport services by intensivists and hospitalists is becoming more common. Transport systems vary from institution to institution, some having a dedicated in‐house pediatric critical care transport teams and others utilizing outside transport services. For transported patients, pediatric hospitalists may serve as referring or accepting attending physician, transport physician, or transport coordinator. Through each of these roles pediatric hospitalists fulfill an essential function in ensuring the safe and timely transport of ill children.
Knowledge
Pediatric hospitalists should be able to:
Compare and contrast advantages and disadvantages between transport modalities including non‐medical, Basic Life Support (BLS) ambulance, Advanced Life Support (ALS) ambulance, Critical Care Team (CCT) ambulance, and specialized Neonatal/Pediatric Critical Care Transport service (Table 1).
Discuss the role of the transport coordinator in effectively triaging to the proper facility, engaging subspecialty services, and determining safest modality of transport.
List the critical history and physical examination elements necessary (to give or obtain) to ensure a safe, effective, expeditious transport, attending to verbal, written, and electronic formats.
Explain how the selection of mode of transportation and team composition are influenced by patients' clinical status and transport logistics such as local traffic conditions, geographical distance, weather, and resources (internal and external) available at the time of the transport.
Describe the role of subspecialist and intensivist consultation in stabilization and management during transport and upon arrival to the destination facility.
Describe the knowledge base and skill set of non‐physician transport team members.
Review the use of standardized procedures on transport, including how they are used by non‐physician team members and the process for creation, approval, and oversight.
Discuss basic altitude physiology and describe how clinical conditions such as hypoxia can be impacted by changes in altitude.
Summarize the transport process, including communications, documentation, and team member roles attending to local context.
Discuss the role of the transport program in the local community, including services provided and outreach education.
| Transport Modality | Advantage | Disadvantage |
|---|---|---|
| Non‐medical (family/caregiver) | Low cost. | No ability to intervene as condition deteriorates. Transport may be delayed due to detours or misdirection. |
| BLS Ambulance or volunteer ambulance | Emergency Medical Technician escort. Some ability to intervene if condition deteriorates. | Little to no pediatric experience thus interventions are limited.Transport may be delayed due to variable ambulance availability. |
| ALS Ambulance or mid‐level transport | Paramedic escort; 1500‐2000 hours of medical training, including O2 administration, nebulized medications, ALS, and airway skills. Greater ability to triage and intervene if condition deteriorates. | Pediatric training not uniform. Paramedics primarily trained for extrication, intervention and rapid transport. |
| CCT ambulance | Critical care nurse team member. Allows for higher level of assessment and intervention. | Pediatric expertise is uncommon. |
| Specialized pediatric‐neonatal critical care transport service | 2‐3 member team composed of RN and RT (pediatric/neonatal critical care) and physician (hospital or emergency medicine, intensivist). Specialized pediatric assessment, monitoring, diagnostic, and interventional skills allows for high level pediatric care from initial referral. | High cost, limited resources. |
Skills
Pediatric hospitalists should be able to*:
(*As appropriate for pediatric hospitalists' role as referring or accepting attending physician, transport physician, or transport coordinator.)
Efficiently obtain or give critical clinical information placing particular emphasis on cardiac, pulmonary, and neurologic disease that could impact the transport process.
Provide recommendations regarding laboratory studies and imaging, as well as therapeutic options for referring facilities and physicians.
Effectively prepare the team to anticipate possible complications during any point in the transport, communicating all available clinical information and creating action plans for potential complications prior to transport.
Manage care during transport at a level and quality of care equivalent to that offered in the acute care hospital setting, limited only by medications and services not available during transport.
Demonstrate strong clinical abilities and expertise over a wide range of pediatric disease processes, making rapid assessments and initiating action plans on transport or at the referring or receiving facility.
Stabilize or remotely direct stabilization of patients at the referring facility and on transport, appropriately utilizing current Pediatric Advanced Life Support guidelines.
Obtain training and maintain skills for transport coordination, referral, and acceptance, including specialized transport issues such as flight physiology as appropriate.
Where pediatric hospitalists' roles include participation in neonatal transport, appropriately utilize current Neonatal Resuscitation Program and STABLE Program guidelines.
Recognize when to consult subspecialist, intensivist, or surgeon.
Accurately document actions and discussions in the medical record.
Attitudes
Pediatric hospitalists should be able to:
Respond promptly and courteously to all calls and requests for transport.
Participate in educational programs for transport team members and community referral sources.
Provide mentorship to junior hospitalists on all aspects of transport including clinical decision making, risk management, customer service, and operational issues.
Communicate effectively with patients and the family/caregiver regarding the need for and their role in the transport, as appropriate.
Establish and maintain good working relationships with referral sources and transport team members.
Recognize and manage patient care related conflicts among transport team members or referring facility in a prompt and judicious manner.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Work with hospital administration, transport team members, and specifically with the transport program manager, on the growth and development of the pediatric transport service and or policies.
Lead, coordinate or participate in ongoing educational opportunities to maintain the skill set of team members and transport coordinators.
Lead, coordinate or participate in the development and implementation of cost‐effective, safe, evidence‐based care pathways to standardize the management of common diagnoses for children transported between facilities.
Lead, coordinate or participate in establishing a multidisciplinary forum such as morbidity and mortality conference to regularly review cases with a goal of improving system‐wide processes and outcomes.
Introduction
Pediatric inter‐facility transport first began in the 1970s when a two‐fold difference in mortality was first demonstrated between neonates cared for solely at a community hospital versus those transferred to a regional center. Today as medicine continues to make technological strides and therapeutic advances, community hospitals often find themselves ill equipped to provide acute care to ill and injured children. The growing trend toward centralized pediatric services further necessitates the transfer of children requiring subspecialty care to a regional facility. From these forces has come the advent of the pediatric critical care transport service. Like their neonatal counterparts, pediatric critical care transport teams are overseen in large part by pediatric intensivists or emergency medicine physicians. However, increasing demand for transport of non‐critically ill children, increasing presence of pediatric hospitalists, and increasing time constraints felt by pediatric intensivists is shifting the paradigm. Co‐direction of pediatric critical care transport services by intensivists and hospitalists is becoming more common. Transport systems vary from institution to institution, some having a dedicated in‐house pediatric critical care transport teams and others utilizing outside transport services. For transported patients, pediatric hospitalists may serve as referring or accepting attending physician, transport physician, or transport coordinator. Through each of these roles pediatric hospitalists fulfill an essential function in ensuring the safe and timely transport of ill children.
Knowledge
Pediatric hospitalists should be able to:
Compare and contrast advantages and disadvantages between transport modalities including non‐medical, Basic Life Support (BLS) ambulance, Advanced Life Support (ALS) ambulance, Critical Care Team (CCT) ambulance, and specialized Neonatal/Pediatric Critical Care Transport service (Table 1).
Discuss the role of the transport coordinator in effectively triaging to the proper facility, engaging subspecialty services, and determining safest modality of transport.
List the critical history and physical examination elements necessary (to give or obtain) to ensure a safe, effective, expeditious transport, attending to verbal, written, and electronic formats.
Explain how the selection of mode of transportation and team composition are influenced by patients' clinical status and transport logistics such as local traffic conditions, geographical distance, weather, and resources (internal and external) available at the time of the transport.
Describe the role of subspecialist and intensivist consultation in stabilization and management during transport and upon arrival to the destination facility.
Describe the knowledge base and skill set of non‐physician transport team members.
Review the use of standardized procedures on transport, including how they are used by non‐physician team members and the process for creation, approval, and oversight.
Discuss basic altitude physiology and describe how clinical conditions such as hypoxia can be impacted by changes in altitude.
Summarize the transport process, including communications, documentation, and team member roles attending to local context.
Discuss the role of the transport program in the local community, including services provided and outreach education.
| Transport Modality | Advantage | Disadvantage |
|---|---|---|
| Non‐medical (family/caregiver) | Low cost. | No ability to intervene as condition deteriorates. Transport may be delayed due to detours or misdirection. |
| BLS Ambulance or volunteer ambulance | Emergency Medical Technician escort. Some ability to intervene if condition deteriorates. | Little to no pediatric experience thus interventions are limited.Transport may be delayed due to variable ambulance availability. |
| ALS Ambulance or mid‐level transport | Paramedic escort; 1500‐2000 hours of medical training, including O2 administration, nebulized medications, ALS, and airway skills. Greater ability to triage and intervene if condition deteriorates. | Pediatric training not uniform. Paramedics primarily trained for extrication, intervention and rapid transport. |
| CCT ambulance | Critical care nurse team member. Allows for higher level of assessment and intervention. | Pediatric expertise is uncommon. |
| Specialized pediatric‐neonatal critical care transport service | 2‐3 member team composed of RN and RT (pediatric/neonatal critical care) and physician (hospital or emergency medicine, intensivist). Specialized pediatric assessment, monitoring, diagnostic, and interventional skills allows for high level pediatric care from initial referral. | High cost, limited resources. |
Skills
Pediatric hospitalists should be able to*:
(*As appropriate for pediatric hospitalists' role as referring or accepting attending physician, transport physician, or transport coordinator.)
Efficiently obtain or give critical clinical information placing particular emphasis on cardiac, pulmonary, and neurologic disease that could impact the transport process.
Provide recommendations regarding laboratory studies and imaging, as well as therapeutic options for referring facilities and physicians.
Effectively prepare the team to anticipate possible complications during any point in the transport, communicating all available clinical information and creating action plans for potential complications prior to transport.
Manage care during transport at a level and quality of care equivalent to that offered in the acute care hospital setting, limited only by medications and services not available during transport.
Demonstrate strong clinical abilities and expertise over a wide range of pediatric disease processes, making rapid assessments and initiating action plans on transport or at the referring or receiving facility.
Stabilize or remotely direct stabilization of patients at the referring facility and on transport, appropriately utilizing current Pediatric Advanced Life Support guidelines.
Obtain training and maintain skills for transport coordination, referral, and acceptance, including specialized transport issues such as flight physiology as appropriate.
Where pediatric hospitalists' roles include participation in neonatal transport, appropriately utilize current Neonatal Resuscitation Program and STABLE Program guidelines.
Recognize when to consult subspecialist, intensivist, or surgeon.
Accurately document actions and discussions in the medical record.
Attitudes
Pediatric hospitalists should be able to:
Respond promptly and courteously to all calls and requests for transport.
Participate in educational programs for transport team members and community referral sources.
Provide mentorship to junior hospitalists on all aspects of transport including clinical decision making, risk management, customer service, and operational issues.
Communicate effectively with patients and the family/caregiver regarding the need for and their role in the transport, as appropriate.
Establish and maintain good working relationships with referral sources and transport team members.
Recognize and manage patient care related conflicts among transport team members or referring facility in a prompt and judicious manner.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Work with hospital administration, transport team members, and specifically with the transport program manager, on the growth and development of the pediatric transport service and or policies.
Lead, coordinate or participate in ongoing educational opportunities to maintain the skill set of team members and transport coordinators.
Lead, coordinate or participate in the development and implementation of cost‐effective, safe, evidence‐based care pathways to standardize the management of common diagnoses for children transported between facilities.
Lead, coordinate or participate in establishing a multidisciplinary forum such as morbidity and mortality conference to regularly review cases with a goal of improving system‐wide processes and outcomes.
Copyright © 2010 Society of Hospital Medicine