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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
Intravenous access and phlebotomy
Introduction
Intravenous (IV) access is the most common procedure performed on a pediatric inpatient unit. IV access may be used for immediate fluid resuscitation, parenteral medication or nutrition delivery, or be placed in anticipation of need for emergent access for medications for patients at risk for acute deterioration such as possible seizure or respiratory compromise. Pediatric hospitalists should be adept at obtaining peripheral IV access in all pediatric patients, and IV or intraosseous (IO) access in critically ill patients. Although not a requirement, many pediatric hospitalists may also obtain skills in the placement of other forms of intravenous access, including central venous catheters and percutaneously inserted central catheters (PICC). Pediatric hospitalists are also often in the best position to obtain venous and arterial blood samples from pediatric patients. Adequate discussion with patients and family/caregiver, and appropriate use of topical anesthesia, anxiolysis, or minimal sedation can create the environment needed for a successful procedure.
Knowledge
Pediatric hospitalists should be able to:
List the indications for intravenous access such as rehydration or resuscitation, parenteral administration of medications and others.
Describe common complications of both peripheral and central IV access, including infiltration, bleeding, infection, and thrombosis.
Compare and contrast the risks and benefits of using peripheral versus central sites for IV access as well as line type, attending to indications and complications for each.
List the indications for arterial blood sampling.
Review the proper method for obtaining venous and arterial blood samples.
Discuss how anatomic location of veins and arteries influences the catheterization technique.
Describe common complications from venous and arterial blood sampling.
Discuss how factors such as age, disease process, and anatomy influence the choice of IV site.
Summarize current literature and national best practices regarding avoidance of catheter‐related bloodstream infections.
Review the options for pain and sedation management, attending to medication and non‐medication interventions by age and developmental stage.
Review methods which can help minimize the number of IVattempts and discuss common complications from IV attempts.
State why use of certain existing and potential venous sites (such as hemodialysis catheters, limb with neurovascular compromise, and others) is contraindicated.
State the relative contraindications to certain IV access sites such as jugular veins with a neighboring ventriculoperitoneal shunt, fracture in limb and others.
State the indications and contraindications for IO access.
Describe the indications, risks, benefits, and alternatives for PICC placement attending to prolonged medication and/or nutrition needs.
Review the common radiographic modalities used to assess proper line placement and function.
Review the indications for subspecialty consultation for IV access or blood sampling, and list commonly accessed subspecialty services, attending to local context.
Skills
Pediatric hospitalists should be able to:
Perform a pre‐procedural evaluation to determine risks and benefits of IV placement.
Correctly assess the need for and order appropriate pain and sedation medication and non‐medication interventions.
Obtain IV access on children of all ages.
Demonstrate proficiency in performing venous and arterial blood sampling (phlebotomy) with and without IV access.
Correctly identify the need for and efficiently offer education to healthcare providers on proper techniques for holding and calming patients before, during, and after access attempts.
Consistently adhere to infection control practices.
Demonstrate proficiency with intraosseous needle placement during emergency situations, and successfully insert the IO needle into a simulator in mock code situations at least once per year.
Identify barriers to efficient, effective IV access and engage subspecialists to assist as appropriate.
Demonstrate proficiency in performing or efficiently accessing appropriate consultants to perform central venous access and PICC lines.
Identify common complications of IVs and blood sampling and respond with appropriate actions.
Demonstrate proficiency in performing or efficiently accessing appropriate consultants to perform basic repairs on central venous lines and PICC lines.
Attitudes
Pediatric hospitalists should be able to:
Work collaboratively with hospital staff and subspecialists to ensure coordinated planning and performance of IV access.
Communicate effectively with patients and the family/caregiver regarding the indications for, risks, benefits, and steps of the procedure.
Role model and advocate for strict adherence to infection control practices.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Lead, coordinate or participate in the development and implementation of cost‐effective, safe, evidence‐based procedures and policies for IV access following national guidelines for infection control.
Work with hospital administration, hospital staff and others to develop and implement standardized documentation tools for venous access procedures.
Lead, coordinate or participate in the development and implementation of a system for review of the efficacy, efficiency and outcomes of intravenous access procedures.
Lead, coordinate or participate in the development and implementation of a system for review of family/caregiver and healthcare provider satisfaction into procedural strategies.
Introduction
Intravenous (IV) access is the most common procedure performed on a pediatric inpatient unit. IV access may be used for immediate fluid resuscitation, parenteral medication or nutrition delivery, or be placed in anticipation of need for emergent access for medications for patients at risk for acute deterioration such as possible seizure or respiratory compromise. Pediatric hospitalists should be adept at obtaining peripheral IV access in all pediatric patients, and IV or intraosseous (IO) access in critically ill patients. Although not a requirement, many pediatric hospitalists may also obtain skills in the placement of other forms of intravenous access, including central venous catheters and percutaneously inserted central catheters (PICC). Pediatric hospitalists are also often in the best position to obtain venous and arterial blood samples from pediatric patients. Adequate discussion with patients and family/caregiver, and appropriate use of topical anesthesia, anxiolysis, or minimal sedation can create the environment needed for a successful procedure.
Knowledge
Pediatric hospitalists should be able to:
List the indications for intravenous access such as rehydration or resuscitation, parenteral administration of medications and others.
Describe common complications of both peripheral and central IV access, including infiltration, bleeding, infection, and thrombosis.
Compare and contrast the risks and benefits of using peripheral versus central sites for IV access as well as line type, attending to indications and complications for each.
List the indications for arterial blood sampling.
Review the proper method for obtaining venous and arterial blood samples.
Discuss how anatomic location of veins and arteries influences the catheterization technique.
Describe common complications from venous and arterial blood sampling.
Discuss how factors such as age, disease process, and anatomy influence the choice of IV site.
Summarize current literature and national best practices regarding avoidance of catheter‐related bloodstream infections.
Review the options for pain and sedation management, attending to medication and non‐medication interventions by age and developmental stage.
Review methods which can help minimize the number of IVattempts and discuss common complications from IV attempts.
State why use of certain existing and potential venous sites (such as hemodialysis catheters, limb with neurovascular compromise, and others) is contraindicated.
State the relative contraindications to certain IV access sites such as jugular veins with a neighboring ventriculoperitoneal shunt, fracture in limb and others.
State the indications and contraindications for IO access.
Describe the indications, risks, benefits, and alternatives for PICC placement attending to prolonged medication and/or nutrition needs.
Review the common radiographic modalities used to assess proper line placement and function.
Review the indications for subspecialty consultation for IV access or blood sampling, and list commonly accessed subspecialty services, attending to local context.
Skills
Pediatric hospitalists should be able to:
Perform a pre‐procedural evaluation to determine risks and benefits of IV placement.
Correctly assess the need for and order appropriate pain and sedation medication and non‐medication interventions.
Obtain IV access on children of all ages.
Demonstrate proficiency in performing venous and arterial blood sampling (phlebotomy) with and without IV access.
Correctly identify the need for and efficiently offer education to healthcare providers on proper techniques for holding and calming patients before, during, and after access attempts.
Consistently adhere to infection control practices.
Demonstrate proficiency with intraosseous needle placement during emergency situations, and successfully insert the IO needle into a simulator in mock code situations at least once per year.
Identify barriers to efficient, effective IV access and engage subspecialists to assist as appropriate.
Demonstrate proficiency in performing or efficiently accessing appropriate consultants to perform central venous access and PICC lines.
Identify common complications of IVs and blood sampling and respond with appropriate actions.
Demonstrate proficiency in performing or efficiently accessing appropriate consultants to perform basic repairs on central venous lines and PICC lines.
Attitudes
Pediatric hospitalists should be able to:
Work collaboratively with hospital staff and subspecialists to ensure coordinated planning and performance of IV access.
Communicate effectively with patients and the family/caregiver regarding the indications for, risks, benefits, and steps of the procedure.
Role model and advocate for strict adherence to infection control practices.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Lead, coordinate or participate in the development and implementation of cost‐effective, safe, evidence‐based procedures and policies for IV access following national guidelines for infection control.
Work with hospital administration, hospital staff and others to develop and implement standardized documentation tools for venous access procedures.
Lead, coordinate or participate in the development and implementation of a system for review of the efficacy, efficiency and outcomes of intravenous access procedures.
Lead, coordinate or participate in the development and implementation of a system for review of family/caregiver and healthcare provider satisfaction into procedural strategies.
Introduction
Intravenous (IV) access is the most common procedure performed on a pediatric inpatient unit. IV access may be used for immediate fluid resuscitation, parenteral medication or nutrition delivery, or be placed in anticipation of need for emergent access for medications for patients at risk for acute deterioration such as possible seizure or respiratory compromise. Pediatric hospitalists should be adept at obtaining peripheral IV access in all pediatric patients, and IV or intraosseous (IO) access in critically ill patients. Although not a requirement, many pediatric hospitalists may also obtain skills in the placement of other forms of intravenous access, including central venous catheters and percutaneously inserted central catheters (PICC). Pediatric hospitalists are also often in the best position to obtain venous and arterial blood samples from pediatric patients. Adequate discussion with patients and family/caregiver, and appropriate use of topical anesthesia, anxiolysis, or minimal sedation can create the environment needed for a successful procedure.
Knowledge
Pediatric hospitalists should be able to:
List the indications for intravenous access such as rehydration or resuscitation, parenteral administration of medications and others.
Describe common complications of both peripheral and central IV access, including infiltration, bleeding, infection, and thrombosis.
Compare and contrast the risks and benefits of using peripheral versus central sites for IV access as well as line type, attending to indications and complications for each.
List the indications for arterial blood sampling.
Review the proper method for obtaining venous and arterial blood samples.
Discuss how anatomic location of veins and arteries influences the catheterization technique.
Describe common complications from venous and arterial blood sampling.
Discuss how factors such as age, disease process, and anatomy influence the choice of IV site.
Summarize current literature and national best practices regarding avoidance of catheter‐related bloodstream infections.
Review the options for pain and sedation management, attending to medication and non‐medication interventions by age and developmental stage.
Review methods which can help minimize the number of IVattempts and discuss common complications from IV attempts.
State why use of certain existing and potential venous sites (such as hemodialysis catheters, limb with neurovascular compromise, and others) is contraindicated.
State the relative contraindications to certain IV access sites such as jugular veins with a neighboring ventriculoperitoneal shunt, fracture in limb and others.
State the indications and contraindications for IO access.
Describe the indications, risks, benefits, and alternatives for PICC placement attending to prolonged medication and/or nutrition needs.
Review the common radiographic modalities used to assess proper line placement and function.
Review the indications for subspecialty consultation for IV access or blood sampling, and list commonly accessed subspecialty services, attending to local context.
Skills
Pediatric hospitalists should be able to:
Perform a pre‐procedural evaluation to determine risks and benefits of IV placement.
Correctly assess the need for and order appropriate pain and sedation medication and non‐medication interventions.
Obtain IV access on children of all ages.
Demonstrate proficiency in performing venous and arterial blood sampling (phlebotomy) with and without IV access.
Correctly identify the need for and efficiently offer education to healthcare providers on proper techniques for holding and calming patients before, during, and after access attempts.
Consistently adhere to infection control practices.
Demonstrate proficiency with intraosseous needle placement during emergency situations, and successfully insert the IO needle into a simulator in mock code situations at least once per year.
Identify barriers to efficient, effective IV access and engage subspecialists to assist as appropriate.
Demonstrate proficiency in performing or efficiently accessing appropriate consultants to perform central venous access and PICC lines.
Identify common complications of IVs and blood sampling and respond with appropriate actions.
Demonstrate proficiency in performing or efficiently accessing appropriate consultants to perform basic repairs on central venous lines and PICC lines.
Attitudes
Pediatric hospitalists should be able to:
Work collaboratively with hospital staff and subspecialists to ensure coordinated planning and performance of IV access.
Communicate effectively with patients and the family/caregiver regarding the indications for, risks, benefits, and steps of the procedure.
Role model and advocate for strict adherence to infection control practices.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Lead, coordinate or participate in the development and implementation of cost‐effective, safe, evidence‐based procedures and policies for IV access following national guidelines for infection control.
Work with hospital administration, hospital staff and others to develop and implement standardized documentation tools for venous access procedures.
Lead, coordinate or participate in the development and implementation of a system for review of the efficacy, efficiency and outcomes of intravenous access procedures.
Lead, coordinate or participate in the development and implementation of a system for review of family/caregiver and healthcare provider satisfaction into procedural strategies.
Copyright © 2010 Society of Hospital Medicine
Fever of unknown origin
Introduction
Fever is the most common presenting complaint in the pediatric outpatient and emergency room setting. In most cases, the etiology of acute fever is readily discernable. In contrast, fever of unknown origin (FUO) is typically defined as fever of 38.3 C (101 F) or greater of at least 14 days duration, with no apparent cause after a thorough history, physical examination, and intense laboratory evaluation of one‐week duration in the outpatient or hospital setting. The differential diagnosis of FUO is very broad, but infection is the most common cause of prolonged fever. Other major etiologic categories include malignancy, rheumatologic conditions, vasculitis syndromes, inflammatory bowel disease, drug fever, and miscellaneous causes. When children require hospitalization for prolonged fever with concern for FUO, pediatric hospitalists should develop a thoughtful, step‐wise, and cost‐effective approach to diagnosis and management
Knowledge
Pediatric hospitalists should be able to:
Discuss the pathophysiologic mechanisms that result in fever.
List the different methods available for obtaining a temperature and explain common errors associated with each.
Differentiate serial or prolonged fevers with known etiologies from FUO.
Describe the differential diagnosis of FUO for children of varying chronological and developmental ages and state the relative prevalence of each etiologic category.
Identify the common infectious causes of FUO, particularly as they differ by region.
Describe the key historical features to elicit including details of the fever pattern and course of illness, immunization status, travel and exposure history, and family history.
Review areas of specific focus when performing the physical examination, including skin and eye findings, lymph nodes, sinuses, liver and spleen size, bone and joint exam, and neurobehavioral state.
List common initial laboratory tests for FUO, recognizing the utility, sensitivity and specificity of diagnostic tests as well as local availability and turnaround times.
Describe the indications for and goals of hospitalization and explain the role of close observation without treatment and daily physical examination.
Discuss the benefits, risks, and potential complications of empiric antibiotic treatment.
Compare and contrast the mechanisms of action and modifying effect on systemic symptoms of anti‐pyretics versus anti‐inflammatory agents noting common side effects.
Identify indications for consultation with a subspecialist.
Summarize the diagnostic value of commonly used second or third tier testing (such as bone scan, bone marrow aspiration/biopsy, repeated blood cultures with fever, and others) where initial testing and observation is non‐diagnostic.
Skills
Pediatric hospitalists should be able to:
Obtain a thorough fever history, including duration, height, pattern, associated signs and symptoms, and response to anti‐pyretics.
Obtain a complete medical history, including signs and symptoms, immunization status, travel history, exposure history (such as animals, tick bites, consumption of raw foods or contaminated water, sick contacts, and others), and family history.
Perform a comprehensive physical examination.
Perform careful reassessments daily and as needed, note changes in clinical status and test results and respond with appropriate actions.
Access and comprehensively review all relevant prior records.
Correctly interpret the results of laboratory or radiological tests performed, engaging subspecialists as needed for interpretation.
Conduct a cost‐effective and evidence‐based evaluation plan, avoiding unnecessary repeat testing.
Correctly order laboratory studies with appropriate detail to ensure specimens are correctly collected and handled.
Appropriately differentiate when to continue inpatient versus outpatient diagnostic evaluation in the face of persistent fever and pending test results.
Formulate appropriate treatment plans for the presumptive or confirmed diagnosis when indicated.
Access and consult subspecialists when indicated.
Create an effective discharge plan including specific expectations for home observation for fever and other symptoms.
Attitudes
Pediatric hospitalists should be able to:
Communicate effectively with the primary care provider regarding the evaluation and treatment conducted in and out of the hospital.
Realize the significant stress placed on the family/caregiver when the diagnosis is unclear and multiple healthcare providers are involved in care.
Educate patients and the family/caregiver regarding the importance of observation and the need for a thoughtful, step‐wise approach to the diagnosis and potential treatment plan.
Recognize the important role pediatric hospitalists play in coordination of care given the often multiple, potentially invasive testing that may be necessary.
Collaborate with subspecialists and the primary care provider to ensure coordinated longitudinal care for children with FUO as appropriate.
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 streamline the admission process to assure smooth, complete transmission of or access to outpatient medical information.
Promote the effective use of hospital resources by adhering to a targeted, step‐wise, and evidence‐based approach to diagnosis and management.
Lead, coordinate or participate in multidisciplinary teams to facilitate discharge planning, including a safe transition from inpatient to outpatient healthcare providers.
Introduction
Fever is the most common presenting complaint in the pediatric outpatient and emergency room setting. In most cases, the etiology of acute fever is readily discernable. In contrast, fever of unknown origin (FUO) is typically defined as fever of 38.3 C (101 F) or greater of at least 14 days duration, with no apparent cause after a thorough history, physical examination, and intense laboratory evaluation of one‐week duration in the outpatient or hospital setting. The differential diagnosis of FUO is very broad, but infection is the most common cause of prolonged fever. Other major etiologic categories include malignancy, rheumatologic conditions, vasculitis syndromes, inflammatory bowel disease, drug fever, and miscellaneous causes. When children require hospitalization for prolonged fever with concern for FUO, pediatric hospitalists should develop a thoughtful, step‐wise, and cost‐effective approach to diagnosis and management
Knowledge
Pediatric hospitalists should be able to:
Discuss the pathophysiologic mechanisms that result in fever.
List the different methods available for obtaining a temperature and explain common errors associated with each.
Differentiate serial or prolonged fevers with known etiologies from FUO.
Describe the differential diagnosis of FUO for children of varying chronological and developmental ages and state the relative prevalence of each etiologic category.
Identify the common infectious causes of FUO, particularly as they differ by region.
Describe the key historical features to elicit including details of the fever pattern and course of illness, immunization status, travel and exposure history, and family history.
Review areas of specific focus when performing the physical examination, including skin and eye findings, lymph nodes, sinuses, liver and spleen size, bone and joint exam, and neurobehavioral state.
List common initial laboratory tests for FUO, recognizing the utility, sensitivity and specificity of diagnostic tests as well as local availability and turnaround times.
Describe the indications for and goals of hospitalization and explain the role of close observation without treatment and daily physical examination.
Discuss the benefits, risks, and potential complications of empiric antibiotic treatment.
Compare and contrast the mechanisms of action and modifying effect on systemic symptoms of anti‐pyretics versus anti‐inflammatory agents noting common side effects.
Identify indications for consultation with a subspecialist.
Summarize the diagnostic value of commonly used second or third tier testing (such as bone scan, bone marrow aspiration/biopsy, repeated blood cultures with fever, and others) where initial testing and observation is non‐diagnostic.
Skills
Pediatric hospitalists should be able to:
Obtain a thorough fever history, including duration, height, pattern, associated signs and symptoms, and response to anti‐pyretics.
Obtain a complete medical history, including signs and symptoms, immunization status, travel history, exposure history (such as animals, tick bites, consumption of raw foods or contaminated water, sick contacts, and others), and family history.
Perform a comprehensive physical examination.
Perform careful reassessments daily and as needed, note changes in clinical status and test results and respond with appropriate actions.
Access and comprehensively review all relevant prior records.
Correctly interpret the results of laboratory or radiological tests performed, engaging subspecialists as needed for interpretation.
Conduct a cost‐effective and evidence‐based evaluation plan, avoiding unnecessary repeat testing.
Correctly order laboratory studies with appropriate detail to ensure specimens are correctly collected and handled.
Appropriately differentiate when to continue inpatient versus outpatient diagnostic evaluation in the face of persistent fever and pending test results.
Formulate appropriate treatment plans for the presumptive or confirmed diagnosis when indicated.
Access and consult subspecialists when indicated.
Create an effective discharge plan including specific expectations for home observation for fever and other symptoms.
Attitudes
Pediatric hospitalists should be able to:
Communicate effectively with the primary care provider regarding the evaluation and treatment conducted in and out of the hospital.
Realize the significant stress placed on the family/caregiver when the diagnosis is unclear and multiple healthcare providers are involved in care.
Educate patients and the family/caregiver regarding the importance of observation and the need for a thoughtful, step‐wise approach to the diagnosis and potential treatment plan.
Recognize the important role pediatric hospitalists play in coordination of care given the often multiple, potentially invasive testing that may be necessary.
Collaborate with subspecialists and the primary care provider to ensure coordinated longitudinal care for children with FUO as appropriate.
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 streamline the admission process to assure smooth, complete transmission of or access to outpatient medical information.
Promote the effective use of hospital resources by adhering to a targeted, step‐wise, and evidence‐based approach to diagnosis and management.
Lead, coordinate or participate in multidisciplinary teams to facilitate discharge planning, including a safe transition from inpatient to outpatient healthcare providers.
Introduction
Fever is the most common presenting complaint in the pediatric outpatient and emergency room setting. In most cases, the etiology of acute fever is readily discernable. In contrast, fever of unknown origin (FUO) is typically defined as fever of 38.3 C (101 F) or greater of at least 14 days duration, with no apparent cause after a thorough history, physical examination, and intense laboratory evaluation of one‐week duration in the outpatient or hospital setting. The differential diagnosis of FUO is very broad, but infection is the most common cause of prolonged fever. Other major etiologic categories include malignancy, rheumatologic conditions, vasculitis syndromes, inflammatory bowel disease, drug fever, and miscellaneous causes. When children require hospitalization for prolonged fever with concern for FUO, pediatric hospitalists should develop a thoughtful, step‐wise, and cost‐effective approach to diagnosis and management
Knowledge
Pediatric hospitalists should be able to:
Discuss the pathophysiologic mechanisms that result in fever.
List the different methods available for obtaining a temperature and explain common errors associated with each.
Differentiate serial or prolonged fevers with known etiologies from FUO.
Describe the differential diagnosis of FUO for children of varying chronological and developmental ages and state the relative prevalence of each etiologic category.
Identify the common infectious causes of FUO, particularly as they differ by region.
Describe the key historical features to elicit including details of the fever pattern and course of illness, immunization status, travel and exposure history, and family history.
Review areas of specific focus when performing the physical examination, including skin and eye findings, lymph nodes, sinuses, liver and spleen size, bone and joint exam, and neurobehavioral state.
List common initial laboratory tests for FUO, recognizing the utility, sensitivity and specificity of diagnostic tests as well as local availability and turnaround times.
Describe the indications for and goals of hospitalization and explain the role of close observation without treatment and daily physical examination.
Discuss the benefits, risks, and potential complications of empiric antibiotic treatment.
Compare and contrast the mechanisms of action and modifying effect on systemic symptoms of anti‐pyretics versus anti‐inflammatory agents noting common side effects.
Identify indications for consultation with a subspecialist.
Summarize the diagnostic value of commonly used second or third tier testing (such as bone scan, bone marrow aspiration/biopsy, repeated blood cultures with fever, and others) where initial testing and observation is non‐diagnostic.
Skills
Pediatric hospitalists should be able to:
Obtain a thorough fever history, including duration, height, pattern, associated signs and symptoms, and response to anti‐pyretics.
Obtain a complete medical history, including signs and symptoms, immunization status, travel history, exposure history (such as animals, tick bites, consumption of raw foods or contaminated water, sick contacts, and others), and family history.
Perform a comprehensive physical examination.
Perform careful reassessments daily and as needed, note changes in clinical status and test results and respond with appropriate actions.
Access and comprehensively review all relevant prior records.
Correctly interpret the results of laboratory or radiological tests performed, engaging subspecialists as needed for interpretation.
Conduct a cost‐effective and evidence‐based evaluation plan, avoiding unnecessary repeat testing.
Correctly order laboratory studies with appropriate detail to ensure specimens are correctly collected and handled.
Appropriately differentiate when to continue inpatient versus outpatient diagnostic evaluation in the face of persistent fever and pending test results.
Formulate appropriate treatment plans for the presumptive or confirmed diagnosis when indicated.
Access and consult subspecialists when indicated.
Create an effective discharge plan including specific expectations for home observation for fever and other symptoms.
Attitudes
Pediatric hospitalists should be able to:
Communicate effectively with the primary care provider regarding the evaluation and treatment conducted in and out of the hospital.
Realize the significant stress placed on the family/caregiver when the diagnosis is unclear and multiple healthcare providers are involved in care.
Educate patients and the family/caregiver regarding the importance of observation and the need for a thoughtful, step‐wise approach to the diagnosis and potential treatment plan.
Recognize the important role pediatric hospitalists play in coordination of care given the often multiple, potentially invasive testing that may be necessary.
Collaborate with subspecialists and the primary care provider to ensure coordinated longitudinal care for children with FUO as appropriate.
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 streamline the admission process to assure smooth, complete transmission of or access to outpatient medical information.
Promote the effective use of hospital resources by adhering to a targeted, step‐wise, and evidence‐based approach to diagnosis and management.
Lead, coordinate or participate in multidisciplinary teams to facilitate discharge planning, including a safe transition from inpatient to outpatient healthcare providers.
Copyright © 2010 Society of Hospital Medicine
Skin and soft tissue infections
Introduction
Skin and soft tissue infections are infections of the skin, subcutaneous tissue and muscle, such as cellulitis or abscess. They do not include infections of the bone, ligaments, cartilage and fibrous tissue. Skin and soft tissue infections are a common cause of hospitalization in children. The most common infectious etiologies of soft tissue infections are streptococcus or staphylococcus species, traditionally treated with Beta‐lactam antibiotics. However, infections due to methicillin‐resistant staphylococcus aureus, particularly community‐acquired methicillin‐resistant staphylococcus aureus (CA‐MRSA), and other organisms are on the rise. Pediatric hospitalists should be aware of the changing epidemiology of pathogens and resistance patterns to ensure efficient and effective treatment of these infections.
Knowledge
Pediatric hospitalists should be able to:
Compare and contrast the key features of the history and physical examination noted in cellulitis versus soft tissue infection.
Provide indications for hospital admission and determine the appropriate level of care.
List common bacterial organisms causing skin and soft tissues infections and state how these differ based on age and exposure histories.
Describe risk factors for infection such as host immunity, dermatoses, environmental exposures and others.
Discuss the influence of community prevalence of skin pathogens and antimicrobial use on predominant organisms and resistance patterns.
Review how patient and antibiotic characteristics influence treatment choices.
List indications for hospitalization.
Discuss how culture and identification of the organism and susceptibility pattern aids in making treatment decisions, as applicable.
Compare and contrast emergent versus urgent complications requiring pediatric surgery consultation, such as necrotizing fasciitis and abscesses.
Explain why early identification and surgical intervention in necrotizing fasciitis can improve outcomes.
Compare and contrast the utility of various imaging modalities such as plain film, nuclear medicine scan, computed tomography and magnetic resonance imaging and list indications for each.
Summarize the approach toward evaluation and treatment of patients with recurrent staphylococcal infections, including indications for evaluation for systemic disease, household colonization, and environmental exposures.
Skills
Pediatric hospitalists should be able to:
Demonstrate proficiency in medical interviewing correctly eliciting information such as onset and timing of spread of infection, past history of similar infections, and specific exposures.
Demonstrate proficiency in conducting a physical examination of skin and soft tissue infections, determining extent and severity of the infection and making proper border demarcations to assist with assessing further spread.
Order appropriate laboratory and radiographic tests to guide treatment and ensure proper isolation.
Accurately interpret radiographic studies and engage consultants as appropriate.
Direct an evidence‐based treatment plan including appropriately selected antibiotic therapy attending to the most likely organisms and antibiotic susceptibility patterns.
Perform careful reassessments daily and as needed, note changes in clinical status, and respond with appropriate actions.
Adjust antibiotics according to the identification of the organism and/or antibiotic susceptibility pattern and clinical progression/emmprovement.
Correctly determine when consultation with a surgeon is indicated.
Consult appropriate subspecialists early to assist in evaluation and treatment as appropriate.
Identify patients requiring extended evaluation for underlying anatomic or systemic disease.
Create a comprehensive discharge plan including home care as appropriate.
Attitudes
Pediatric hospitalists should be able to:
Recognize the importance of consulting with interdisciplinary teams such as pediatric surgeons, radiologists, pharmacists, and the laboratory early in the hospital course to facilitate rapid diagnosis, treatment and discharge.
Communicate effectively with patients, family/caregiver, primary care provider and subspecialists regarding the reasons for diagnostic testing and treatment choices.
Educate the family/caregiver on the etiology of the infection, including the importance of hand washing and minimizing environmental exposure in the prevention of infection.
Display proactive, engaged behavior regarding proper isolation measures to prevent spread of the etiologic agent in the hospital.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Work with hospital administration and subspecialists to acquire local laboratory testing that is critical for evaluation and management, such as susceptibility testing.
Incorporate knowledge of outcomes research, changing microbial epidemiology and resistance patterns, cost, and management strategies into patient care.
Lead, coordinate, or participate in the development and implementation of cost‐effective, safe, evidence‐based care pathways to standardize the evaluation and management of skin and soft tissue infections.
Introduction
Skin and soft tissue infections are infections of the skin, subcutaneous tissue and muscle, such as cellulitis or abscess. They do not include infections of the bone, ligaments, cartilage and fibrous tissue. Skin and soft tissue infections are a common cause of hospitalization in children. The most common infectious etiologies of soft tissue infections are streptococcus or staphylococcus species, traditionally treated with Beta‐lactam antibiotics. However, infections due to methicillin‐resistant staphylococcus aureus, particularly community‐acquired methicillin‐resistant staphylococcus aureus (CA‐MRSA), and other organisms are on the rise. Pediatric hospitalists should be aware of the changing epidemiology of pathogens and resistance patterns to ensure efficient and effective treatment of these infections.
Knowledge
Pediatric hospitalists should be able to:
Compare and contrast the key features of the history and physical examination noted in cellulitis versus soft tissue infection.
Provide indications for hospital admission and determine the appropriate level of care.
List common bacterial organisms causing skin and soft tissues infections and state how these differ based on age and exposure histories.
Describe risk factors for infection such as host immunity, dermatoses, environmental exposures and others.
Discuss the influence of community prevalence of skin pathogens and antimicrobial use on predominant organisms and resistance patterns.
Review how patient and antibiotic characteristics influence treatment choices.
List indications for hospitalization.
Discuss how culture and identification of the organism and susceptibility pattern aids in making treatment decisions, as applicable.
Compare and contrast emergent versus urgent complications requiring pediatric surgery consultation, such as necrotizing fasciitis and abscesses.
Explain why early identification and surgical intervention in necrotizing fasciitis can improve outcomes.
Compare and contrast the utility of various imaging modalities such as plain film, nuclear medicine scan, computed tomography and magnetic resonance imaging and list indications for each.
Summarize the approach toward evaluation and treatment of patients with recurrent staphylococcal infections, including indications for evaluation for systemic disease, household colonization, and environmental exposures.
Skills
Pediatric hospitalists should be able to:
Demonstrate proficiency in medical interviewing correctly eliciting information such as onset and timing of spread of infection, past history of similar infections, and specific exposures.
Demonstrate proficiency in conducting a physical examination of skin and soft tissue infections, determining extent and severity of the infection and making proper border demarcations to assist with assessing further spread.
Order appropriate laboratory and radiographic tests to guide treatment and ensure proper isolation.
Accurately interpret radiographic studies and engage consultants as appropriate.
Direct an evidence‐based treatment plan including appropriately selected antibiotic therapy attending to the most likely organisms and antibiotic susceptibility patterns.
Perform careful reassessments daily and as needed, note changes in clinical status, and respond with appropriate actions.
Adjust antibiotics according to the identification of the organism and/or antibiotic susceptibility pattern and clinical progression/emmprovement.
Correctly determine when consultation with a surgeon is indicated.
Consult appropriate subspecialists early to assist in evaluation and treatment as appropriate.
Identify patients requiring extended evaluation for underlying anatomic or systemic disease.
Create a comprehensive discharge plan including home care as appropriate.
Attitudes
Pediatric hospitalists should be able to:
Recognize the importance of consulting with interdisciplinary teams such as pediatric surgeons, radiologists, pharmacists, and the laboratory early in the hospital course to facilitate rapid diagnosis, treatment and discharge.
Communicate effectively with patients, family/caregiver, primary care provider and subspecialists regarding the reasons for diagnostic testing and treatment choices.
Educate the family/caregiver on the etiology of the infection, including the importance of hand washing and minimizing environmental exposure in the prevention of infection.
Display proactive, engaged behavior regarding proper isolation measures to prevent spread of the etiologic agent in the hospital.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Work with hospital administration and subspecialists to acquire local laboratory testing that is critical for evaluation and management, such as susceptibility testing.
Incorporate knowledge of outcomes research, changing microbial epidemiology and resistance patterns, cost, and management strategies into patient care.
Lead, coordinate, or participate in the development and implementation of cost‐effective, safe, evidence‐based care pathways to standardize the evaluation and management of skin and soft tissue infections.
Introduction
Skin and soft tissue infections are infections of the skin, subcutaneous tissue and muscle, such as cellulitis or abscess. They do not include infections of the bone, ligaments, cartilage and fibrous tissue. Skin and soft tissue infections are a common cause of hospitalization in children. The most common infectious etiologies of soft tissue infections are streptococcus or staphylococcus species, traditionally treated with Beta‐lactam antibiotics. However, infections due to methicillin‐resistant staphylococcus aureus, particularly community‐acquired methicillin‐resistant staphylococcus aureus (CA‐MRSA), and other organisms are on the rise. Pediatric hospitalists should be aware of the changing epidemiology of pathogens and resistance patterns to ensure efficient and effective treatment of these infections.
Knowledge
Pediatric hospitalists should be able to:
Compare and contrast the key features of the history and physical examination noted in cellulitis versus soft tissue infection.
Provide indications for hospital admission and determine the appropriate level of care.
List common bacterial organisms causing skin and soft tissues infections and state how these differ based on age and exposure histories.
Describe risk factors for infection such as host immunity, dermatoses, environmental exposures and others.
Discuss the influence of community prevalence of skin pathogens and antimicrobial use on predominant organisms and resistance patterns.
Review how patient and antibiotic characteristics influence treatment choices.
List indications for hospitalization.
Discuss how culture and identification of the organism and susceptibility pattern aids in making treatment decisions, as applicable.
Compare and contrast emergent versus urgent complications requiring pediatric surgery consultation, such as necrotizing fasciitis and abscesses.
Explain why early identification and surgical intervention in necrotizing fasciitis can improve outcomes.
Compare and contrast the utility of various imaging modalities such as plain film, nuclear medicine scan, computed tomography and magnetic resonance imaging and list indications for each.
Summarize the approach toward evaluation and treatment of patients with recurrent staphylococcal infections, including indications for evaluation for systemic disease, household colonization, and environmental exposures.
Skills
Pediatric hospitalists should be able to:
Demonstrate proficiency in medical interviewing correctly eliciting information such as onset and timing of spread of infection, past history of similar infections, and specific exposures.
Demonstrate proficiency in conducting a physical examination of skin and soft tissue infections, determining extent and severity of the infection and making proper border demarcations to assist with assessing further spread.
Order appropriate laboratory and radiographic tests to guide treatment and ensure proper isolation.
Accurately interpret radiographic studies and engage consultants as appropriate.
Direct an evidence‐based treatment plan including appropriately selected antibiotic therapy attending to the most likely organisms and antibiotic susceptibility patterns.
Perform careful reassessments daily and as needed, note changes in clinical status, and respond with appropriate actions.
Adjust antibiotics according to the identification of the organism and/or antibiotic susceptibility pattern and clinical progression/emmprovement.
Correctly determine when consultation with a surgeon is indicated.
Consult appropriate subspecialists early to assist in evaluation and treatment as appropriate.
Identify patients requiring extended evaluation for underlying anatomic or systemic disease.
Create a comprehensive discharge plan including home care as appropriate.
Attitudes
Pediatric hospitalists should be able to:
Recognize the importance of consulting with interdisciplinary teams such as pediatric surgeons, radiologists, pharmacists, and the laboratory early in the hospital course to facilitate rapid diagnosis, treatment and discharge.
Communicate effectively with patients, family/caregiver, primary care provider and subspecialists regarding the reasons for diagnostic testing and treatment choices.
Educate the family/caregiver on the etiology of the infection, including the importance of hand washing and minimizing environmental exposure in the prevention of infection.
Display proactive, engaged behavior regarding proper isolation measures to prevent spread of the etiologic agent in the hospital.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Work with hospital administration and subspecialists to acquire local laboratory testing that is critical for evaluation and management, such as susceptibility testing.
Incorporate knowledge of outcomes research, changing microbial epidemiology and resistance patterns, cost, and management strategies into patient care.
Lead, coordinate, or participate in the development and implementation of cost‐effective, safe, evidence‐based care pathways to standardize the evaluation and management of skin and soft tissue infections.
Copyright © 2010 Society of Hospital Medicine
Gastroenteritis
Introduction
Gastroenteritis is one of the most common diseases of childhood, accounting for thousands of hospital admissions each year. Admission to the hospital can be prevented in most cases with appropriate use of oral rehydration. Although uncommon in developed countries, morbidity and mortality can occur, especially among hospitalized infants with severe dehydration, electrolyte abnormalities, sepsis or malnutrition. Misdiagnosis of gastroenteritis may occur, particularly when vomiting is the predominant symptom, which can lead to inappropriate treatment for potentially life threatening conditions. Pediatric hospitalists routinely encounter patients with gastroenteritis and should provide immediate medical care in an efficient and effective manner.
Knowledge
Pediatric hospitalists should be able to:
Review the elements of the history which are pertinent to obtain, such as travel, immunization status, water source, daycare attendance, food sources and methods of preparation and others.
Describe the elements of the physical examination that aid in supporting or refuting the diagnosis.
Cite critical medical (such as diabetic ketoacidosis, CNS infection or injury, malabsorption, toxic ingestion, inborn errors of metabolism, and others) and surgical (such as bowel obstruction, testicular/ovarian torsion, and others) differential diagnoses to consider and describe the key history and physical examination findings of each, attending to differences by age.
Compare and contrast the differential diagnoses of isolated emesis versus emesis with diarrhea.
Describe the differences in approach toward diagnosis and treatment for patients with underlying co‐morbidities or receiving treatments which may affect potential pathogens.
List the common etiologies for gastroenteritis depending upon geographic location and age.
Summarize the literature on gastroenteritis epidemiology, immunizations, and global health impact.
Describe the epidemiologic factors associated with different pathogens, such as close contact with other symptomatic individuals, intake of contaminated food or water, case clustering, and recent travel to an endemic area.
Compare and contrast clinical findings which are more suggestive of viral, bacterial, and parasitic gastroenteritis.
Discuss the role of infection control in the hospital, as well as public health reporting mandates.
List the indications for diagnostic laboratory tests, including stool, blood, and urine studies, attending to age groups, predictive value of tests, and cost‐effectiveness.
Describe the role of oral rehydration solutions in the treatment of dehydration related to gastroenteritis.
List the indications for hospital admission, including the need for intravenous fluids, correction of fluid, electrolyte and acid base disturbances, close clinical monitoring and/or further diagnostic evaluation.
Skills
Pediatric hospitalists should be able to:
Correctly diagnose gastroenteritis by efficiently performing an accurate history and physical examination, determining if key features of the disease are present.
Recognize and correctly manage dehydration, fluid, electrolyte and acid base derangements.
Recognize and assess patients for complications of gastroenteritis such as sepsis, significant ileus, and hemolytic uremic syndrome.
Identify findings of and appropriately evaluate patients for alternative conditions.
Identify and appropriately treat patients at risk for unusual pathogens.
Direct a cost‐effective and evidence‐based evaluation and treatment plan, especially with regard to laboratory studies, antibiotics, and oral or intravenous fluid resuscitation.
Consistently adhere to infection control practices.
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 infection control practices to decrease pathogen transmission.
Ensure coordination of care for diagnostic tests and treatment between subspecialists.
Realize the importance of educating the family/caregiver on the natural course of disease to manage expectations for improvement.
Role model and advocate for strict adherence to infection control practices.
Communicate effectively with patients, the family/caregiver, and healthcare providers regarding findings, care plans, and anticipated health needs after discharge.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Lead, coordinate or participate in the development and implementation of cost‐effective, safe, evidence‐based care pathways to standardize the evaluation and management for hospitalized children with gastroenteritis.
Work with hospital administration to create and sustain a process to follow up on laboratory tests pending at discharge.
Collaborate with institutional infection control practitioners to improve processes to prevent nosocomial infection related to gastroenteritis.
Work with hospital and community leaders to assure consistent public health reporting of appropriate infections and response to trends.
Introduction
Gastroenteritis is one of the most common diseases of childhood, accounting for thousands of hospital admissions each year. Admission to the hospital can be prevented in most cases with appropriate use of oral rehydration. Although uncommon in developed countries, morbidity and mortality can occur, especially among hospitalized infants with severe dehydration, electrolyte abnormalities, sepsis or malnutrition. Misdiagnosis of gastroenteritis may occur, particularly when vomiting is the predominant symptom, which can lead to inappropriate treatment for potentially life threatening conditions. Pediatric hospitalists routinely encounter patients with gastroenteritis and should provide immediate medical care in an efficient and effective manner.
Knowledge
Pediatric hospitalists should be able to:
Review the elements of the history which are pertinent to obtain, such as travel, immunization status, water source, daycare attendance, food sources and methods of preparation and others.
Describe the elements of the physical examination that aid in supporting or refuting the diagnosis.
Cite critical medical (such as diabetic ketoacidosis, CNS infection or injury, malabsorption, toxic ingestion, inborn errors of metabolism, and others) and surgical (such as bowel obstruction, testicular/ovarian torsion, and others) differential diagnoses to consider and describe the key history and physical examination findings of each, attending to differences by age.
Compare and contrast the differential diagnoses of isolated emesis versus emesis with diarrhea.
Describe the differences in approach toward diagnosis and treatment for patients with underlying co‐morbidities or receiving treatments which may affect potential pathogens.
List the common etiologies for gastroenteritis depending upon geographic location and age.
Summarize the literature on gastroenteritis epidemiology, immunizations, and global health impact.
Describe the epidemiologic factors associated with different pathogens, such as close contact with other symptomatic individuals, intake of contaminated food or water, case clustering, and recent travel to an endemic area.
Compare and contrast clinical findings which are more suggestive of viral, bacterial, and parasitic gastroenteritis.
Discuss the role of infection control in the hospital, as well as public health reporting mandates.
List the indications for diagnostic laboratory tests, including stool, blood, and urine studies, attending to age groups, predictive value of tests, and cost‐effectiveness.
Describe the role of oral rehydration solutions in the treatment of dehydration related to gastroenteritis.
List the indications for hospital admission, including the need for intravenous fluids, correction of fluid, electrolyte and acid base disturbances, close clinical monitoring and/or further diagnostic evaluation.
Skills
Pediatric hospitalists should be able to:
Correctly diagnose gastroenteritis by efficiently performing an accurate history and physical examination, determining if key features of the disease are present.
Recognize and correctly manage dehydration, fluid, electrolyte and acid base derangements.
Recognize and assess patients for complications of gastroenteritis such as sepsis, significant ileus, and hemolytic uremic syndrome.
Identify findings of and appropriately evaluate patients for alternative conditions.
Identify and appropriately treat patients at risk for unusual pathogens.
Direct a cost‐effective and evidence‐based evaluation and treatment plan, especially with regard to laboratory studies, antibiotics, and oral or intravenous fluid resuscitation.
Consistently adhere to infection control practices.
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 infection control practices to decrease pathogen transmission.
Ensure coordination of care for diagnostic tests and treatment between subspecialists.
Realize the importance of educating the family/caregiver on the natural course of disease to manage expectations for improvement.
Role model and advocate for strict adherence to infection control practices.
Communicate effectively with patients, the family/caregiver, and healthcare providers regarding findings, care plans, and anticipated health needs after discharge.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Lead, coordinate or participate in the development and implementation of cost‐effective, safe, evidence‐based care pathways to standardize the evaluation and management for hospitalized children with gastroenteritis.
Work with hospital administration to create and sustain a process to follow up on laboratory tests pending at discharge.
Collaborate with institutional infection control practitioners to improve processes to prevent nosocomial infection related to gastroenteritis.
Work with hospital and community leaders to assure consistent public health reporting of appropriate infections and response to trends.
Introduction
Gastroenteritis is one of the most common diseases of childhood, accounting for thousands of hospital admissions each year. Admission to the hospital can be prevented in most cases with appropriate use of oral rehydration. Although uncommon in developed countries, morbidity and mortality can occur, especially among hospitalized infants with severe dehydration, electrolyte abnormalities, sepsis or malnutrition. Misdiagnosis of gastroenteritis may occur, particularly when vomiting is the predominant symptom, which can lead to inappropriate treatment for potentially life threatening conditions. Pediatric hospitalists routinely encounter patients with gastroenteritis and should provide immediate medical care in an efficient and effective manner.
Knowledge
Pediatric hospitalists should be able to:
Review the elements of the history which are pertinent to obtain, such as travel, immunization status, water source, daycare attendance, food sources and methods of preparation and others.
Describe the elements of the physical examination that aid in supporting or refuting the diagnosis.
Cite critical medical (such as diabetic ketoacidosis, CNS infection or injury, malabsorption, toxic ingestion, inborn errors of metabolism, and others) and surgical (such as bowel obstruction, testicular/ovarian torsion, and others) differential diagnoses to consider and describe the key history and physical examination findings of each, attending to differences by age.
Compare and contrast the differential diagnoses of isolated emesis versus emesis with diarrhea.
Describe the differences in approach toward diagnosis and treatment for patients with underlying co‐morbidities or receiving treatments which may affect potential pathogens.
List the common etiologies for gastroenteritis depending upon geographic location and age.
Summarize the literature on gastroenteritis epidemiology, immunizations, and global health impact.
Describe the epidemiologic factors associated with different pathogens, such as close contact with other symptomatic individuals, intake of contaminated food or water, case clustering, and recent travel to an endemic area.
Compare and contrast clinical findings which are more suggestive of viral, bacterial, and parasitic gastroenteritis.
Discuss the role of infection control in the hospital, as well as public health reporting mandates.
List the indications for diagnostic laboratory tests, including stool, blood, and urine studies, attending to age groups, predictive value of tests, and cost‐effectiveness.
Describe the role of oral rehydration solutions in the treatment of dehydration related to gastroenteritis.
List the indications for hospital admission, including the need for intravenous fluids, correction of fluid, electrolyte and acid base disturbances, close clinical monitoring and/or further diagnostic evaluation.
Skills
Pediatric hospitalists should be able to:
Correctly diagnose gastroenteritis by efficiently performing an accurate history and physical examination, determining if key features of the disease are present.
Recognize and correctly manage dehydration, fluid, electrolyte and acid base derangements.
Recognize and assess patients for complications of gastroenteritis such as sepsis, significant ileus, and hemolytic uremic syndrome.
Identify findings of and appropriately evaluate patients for alternative conditions.
Identify and appropriately treat patients at risk for unusual pathogens.
Direct a cost‐effective and evidence‐based evaluation and treatment plan, especially with regard to laboratory studies, antibiotics, and oral or intravenous fluid resuscitation.
Consistently adhere to infection control practices.
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 infection control practices to decrease pathogen transmission.
Ensure coordination of care for diagnostic tests and treatment between subspecialists.
Realize the importance of educating the family/caregiver on the natural course of disease to manage expectations for improvement.
Role model and advocate for strict adherence to infection control practices.
Communicate effectively with patients, the family/caregiver, and healthcare providers regarding findings, care plans, and anticipated health needs after discharge.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Lead, coordinate or participate in the development and implementation of cost‐effective, safe, evidence‐based care pathways to standardize the evaluation and management for hospitalized children with gastroenteritis.
Work with hospital administration to create and sustain a process to follow up on laboratory tests pending at discharge.
Collaborate with institutional infection control practitioners to improve processes to prevent nosocomial infection related to gastroenteritis.
Work with hospital and community leaders to assure consistent public health reporting of appropriate infections and response to trends.
Copyright © 2010 Society of Hospital Medicine