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Alcohol and drug withdrawal
Alcohol and drug withdrawal is a set of signs and symptoms that develop in association with a sudden cessation or taper in alcohol intake or use of prescription (particularly narcotic medications), over‐the‐counter (OTC), or illicit drugs. Withdrawal may occur prior to hospitalization or during the course of hospitalization. The Healthcare Cost and Utilization Project (HCUP) estimates 195,000 discharges for alcohol/drug abuse or dependency in 2002. These patients were hospitalized for a mean of 3.9 days with mean charges of $7,266 per patient. Hospitalists can lead their institutions in evidence based treatment protocols that improve care, reduce costs and length of stay, and facilitate better overall outcomes in patients with substance related withdrawal syndromes.
KNOWLEDGE
Hospitalists should be able to:
Describe the effects of drug and alcohol withdrawal on medical illness and the effects of medical illness on substance withdrawal.
Recognize the complications from substance use and dependency.
Distinguish alcohol or drug withdrawal from other causes of delirium.
Describe the indicated tests required to evaluate alcohol or drug withdrawal.
Identify patients at increased risk for drug and alcohol withdrawal using current diagnostic criteria for withdrawal.
Explain indications, contraindications and mechanisms of action of pharmacologic agents used to treat acute alcohol and drug withdrawal.
Identify local trends in illicit drug use.
Determine the best setting within the hospital to initiate, monitor, evaluate and treat patients with drug or alcohol withdrawal.
Explain patient characteristics that on admission portend poor prognosis.
Explain goals for hospital discharge, including specific measures of clinical stability for safe care transition.
SKILLS
Hospitalists should be able to:
Elicit a thorough and relevant history, with emphasis on substance use.
Recognize the symptoms and signs of alcohol and drug withdrawal, including prescription and OTC drugs.
Differentiate delirium tremens from other alcohol withdrawal syndromes.
Assess for common co‐morbidities in patients with a history of alcohol and drug use.
Perform a rapid, efficient and targeted physical examination to assess alcohol or drug withdrawal and determine life‐threatening co‐morbidities.
Apply DSM‐IV Diagnostic Criteria for Alcohol Withdrawal.
Formulate a treatment plan, tailored to the individual patient, which may include appropriate pharmacologic agents and dosing, route of administration, and nutritional supplementation.
Integrate existing literature and federal regulations into the management of patients with opioid withdrawal syndromes. for patients who are undergoing existing treatment for opioid dependency, communicate with outpatient treatment centers and integrate dosing regimens into care management.
Manage withdrawal syndromes in patients with concomitant medical or surgical issues.
Determine need for the use of restraints to ensure patient safety.
Reassure, reorient, and frequently monitor the patient in a calm environment.
Assess patients with suspected alcohol or drug withdrawal in a timely manner, identify the level of care required, and manage or co‐manage the patient with the primary requesting service.
ATTITUDES
Hospitalists should be able to:
Use the acute hospitalization as an opportunity to counsel patients about abstinence, recovery and the medical risks of drug and alcohol use.
Communicate with patients and families to explain goals of care plan, discharge instructions and management after release from hospital.
Appreciate the indications for specialty consultations.
Initiate prevention measures prior to discharge, including alcohol and drug cessation measures.
Manage the hospitalized patient with substance use in a non‐judgmental manner.
Employ a multidisciplinary approach, which may include psychiatry, pharmacy, nursing and social services, in the treatment of patients with substance use or dependency.
Establish and maintain an open dialogue with patients and families regarding care goals and limitations.
Appreciate and document the value of appropriate treatment in reducing mortality, duration of delirium, time required to control agitation, adequate control of delirium, treatment of complications, and cost.
Facilitate discharge planning early in the hospitalization, including communicating with the primary care provider and presenting the patient with contact information for follow‐up care, support and rehabilitation.
Utilize evidence based national recommendations to guide diagnosis, monitoring and treatment of withdrawal symptoms.
SYSTEM ORGANIZATION AND IMPROVEMENT
To improve efficiency and quality within their organizations, Hospitalists should:
Lead, coordinate or participate in the development and promotion of guidelines and/or pathways that facilitate efficient and timely evaluation and treatment of patients with alcohol and drug withdrawal.
Promote the development and use of evidence based guidelines and protocols for the treatment of withdrawal syndromes.
Advocate for hospital resources to improve the care of patients with substance withdrawal, and the environment in which the care is delivered.
Lead, coordinate or participate in multidisciplinary teams, which may include psychiatry, to improve patient safety and management strategies for patients with substance abuse.
Alcohol and drug withdrawal is a set of signs and symptoms that develop in association with a sudden cessation or taper in alcohol intake or use of prescription (particularly narcotic medications), over‐the‐counter (OTC), or illicit drugs. Withdrawal may occur prior to hospitalization or during the course of hospitalization. The Healthcare Cost and Utilization Project (HCUP) estimates 195,000 discharges for alcohol/drug abuse or dependency in 2002. These patients were hospitalized for a mean of 3.9 days with mean charges of $7,266 per patient. Hospitalists can lead their institutions in evidence based treatment protocols that improve care, reduce costs and length of stay, and facilitate better overall outcomes in patients with substance related withdrawal syndromes.
KNOWLEDGE
Hospitalists should be able to:
Describe the effects of drug and alcohol withdrawal on medical illness and the effects of medical illness on substance withdrawal.
Recognize the complications from substance use and dependency.
Distinguish alcohol or drug withdrawal from other causes of delirium.
Describe the indicated tests required to evaluate alcohol or drug withdrawal.
Identify patients at increased risk for drug and alcohol withdrawal using current diagnostic criteria for withdrawal.
Explain indications, contraindications and mechanisms of action of pharmacologic agents used to treat acute alcohol and drug withdrawal.
Identify local trends in illicit drug use.
Determine the best setting within the hospital to initiate, monitor, evaluate and treat patients with drug or alcohol withdrawal.
Explain patient characteristics that on admission portend poor prognosis.
Explain goals for hospital discharge, including specific measures of clinical stability for safe care transition.
SKILLS
Hospitalists should be able to:
Elicit a thorough and relevant history, with emphasis on substance use.
Recognize the symptoms and signs of alcohol and drug withdrawal, including prescription and OTC drugs.
Differentiate delirium tremens from other alcohol withdrawal syndromes.
Assess for common co‐morbidities in patients with a history of alcohol and drug use.
Perform a rapid, efficient and targeted physical examination to assess alcohol or drug withdrawal and determine life‐threatening co‐morbidities.
Apply DSM‐IV Diagnostic Criteria for Alcohol Withdrawal.
Formulate a treatment plan, tailored to the individual patient, which may include appropriate pharmacologic agents and dosing, route of administration, and nutritional supplementation.
Integrate existing literature and federal regulations into the management of patients with opioid withdrawal syndromes. for patients who are undergoing existing treatment for opioid dependency, communicate with outpatient treatment centers and integrate dosing regimens into care management.
Manage withdrawal syndromes in patients with concomitant medical or surgical issues.
Determine need for the use of restraints to ensure patient safety.
Reassure, reorient, and frequently monitor the patient in a calm environment.
Assess patients with suspected alcohol or drug withdrawal in a timely manner, identify the level of care required, and manage or co‐manage the patient with the primary requesting service.
ATTITUDES
Hospitalists should be able to:
Use the acute hospitalization as an opportunity to counsel patients about abstinence, recovery and the medical risks of drug and alcohol use.
Communicate with patients and families to explain goals of care plan, discharge instructions and management after release from hospital.
Appreciate the indications for specialty consultations.
Initiate prevention measures prior to discharge, including alcohol and drug cessation measures.
Manage the hospitalized patient with substance use in a non‐judgmental manner.
Employ a multidisciplinary approach, which may include psychiatry, pharmacy, nursing and social services, in the treatment of patients with substance use or dependency.
Establish and maintain an open dialogue with patients and families regarding care goals and limitations.
Appreciate and document the value of appropriate treatment in reducing mortality, duration of delirium, time required to control agitation, adequate control of delirium, treatment of complications, and cost.
Facilitate discharge planning early in the hospitalization, including communicating with the primary care provider and presenting the patient with contact information for follow‐up care, support and rehabilitation.
Utilize evidence based national recommendations to guide diagnosis, monitoring and treatment of withdrawal symptoms.
SYSTEM ORGANIZATION AND IMPROVEMENT
To improve efficiency and quality within their organizations, Hospitalists should:
Lead, coordinate or participate in the development and promotion of guidelines and/or pathways that facilitate efficient and timely evaluation and treatment of patients with alcohol and drug withdrawal.
Promote the development and use of evidence based guidelines and protocols for the treatment of withdrawal syndromes.
Advocate for hospital resources to improve the care of patients with substance withdrawal, and the environment in which the care is delivered.
Lead, coordinate or participate in multidisciplinary teams, which may include psychiatry, to improve patient safety and management strategies for patients with substance abuse.
Alcohol and drug withdrawal is a set of signs and symptoms that develop in association with a sudden cessation or taper in alcohol intake or use of prescription (particularly narcotic medications), over‐the‐counter (OTC), or illicit drugs. Withdrawal may occur prior to hospitalization or during the course of hospitalization. The Healthcare Cost and Utilization Project (HCUP) estimates 195,000 discharges for alcohol/drug abuse or dependency in 2002. These patients were hospitalized for a mean of 3.9 days with mean charges of $7,266 per patient. Hospitalists can lead their institutions in evidence based treatment protocols that improve care, reduce costs and length of stay, and facilitate better overall outcomes in patients with substance related withdrawal syndromes.
KNOWLEDGE
Hospitalists should be able to:
Describe the effects of drug and alcohol withdrawal on medical illness and the effects of medical illness on substance withdrawal.
Recognize the complications from substance use and dependency.
Distinguish alcohol or drug withdrawal from other causes of delirium.
Describe the indicated tests required to evaluate alcohol or drug withdrawal.
Identify patients at increased risk for drug and alcohol withdrawal using current diagnostic criteria for withdrawal.
Explain indications, contraindications and mechanisms of action of pharmacologic agents used to treat acute alcohol and drug withdrawal.
Identify local trends in illicit drug use.
Determine the best setting within the hospital to initiate, monitor, evaluate and treat patients with drug or alcohol withdrawal.
Explain patient characteristics that on admission portend poor prognosis.
Explain goals for hospital discharge, including specific measures of clinical stability for safe care transition.
SKILLS
Hospitalists should be able to:
Elicit a thorough and relevant history, with emphasis on substance use.
Recognize the symptoms and signs of alcohol and drug withdrawal, including prescription and OTC drugs.
Differentiate delirium tremens from other alcohol withdrawal syndromes.
Assess for common co‐morbidities in patients with a history of alcohol and drug use.
Perform a rapid, efficient and targeted physical examination to assess alcohol or drug withdrawal and determine life‐threatening co‐morbidities.
Apply DSM‐IV Diagnostic Criteria for Alcohol Withdrawal.
Formulate a treatment plan, tailored to the individual patient, which may include appropriate pharmacologic agents and dosing, route of administration, and nutritional supplementation.
Integrate existing literature and federal regulations into the management of patients with opioid withdrawal syndromes. for patients who are undergoing existing treatment for opioid dependency, communicate with outpatient treatment centers and integrate dosing regimens into care management.
Manage withdrawal syndromes in patients with concomitant medical or surgical issues.
Determine need for the use of restraints to ensure patient safety.
Reassure, reorient, and frequently monitor the patient in a calm environment.
Assess patients with suspected alcohol or drug withdrawal in a timely manner, identify the level of care required, and manage or co‐manage the patient with the primary requesting service.
ATTITUDES
Hospitalists should be able to:
Use the acute hospitalization as an opportunity to counsel patients about abstinence, recovery and the medical risks of drug and alcohol use.
Communicate with patients and families to explain goals of care plan, discharge instructions and management after release from hospital.
Appreciate the indications for specialty consultations.
Initiate prevention measures prior to discharge, including alcohol and drug cessation measures.
Manage the hospitalized patient with substance use in a non‐judgmental manner.
Employ a multidisciplinary approach, which may include psychiatry, pharmacy, nursing and social services, in the treatment of patients with substance use or dependency.
Establish and maintain an open dialogue with patients and families regarding care goals and limitations.
Appreciate and document the value of appropriate treatment in reducing mortality, duration of delirium, time required to control agitation, adequate control of delirium, treatment of complications, and cost.
Facilitate discharge planning early in the hospitalization, including communicating with the primary care provider and presenting the patient with contact information for follow‐up care, support and rehabilitation.
Utilize evidence based national recommendations to guide diagnosis, monitoring and treatment of withdrawal symptoms.
SYSTEM ORGANIZATION AND IMPROVEMENT
To improve efficiency and quality within their organizations, Hospitalists should:
Lead, coordinate or participate in the development and promotion of guidelines and/or pathways that facilitate efficient and timely evaluation and treatment of patients with alcohol and drug withdrawal.
Promote the development and use of evidence based guidelines and protocols for the treatment of withdrawal syndromes.
Advocate for hospital resources to improve the care of patients with substance withdrawal, and the environment in which the care is delivered.
Lead, coordinate or participate in multidisciplinary teams, which may include psychiatry, to improve patient safety and management strategies for patients with substance abuse.
Copyright © 2006 Society of Hospital Medicine
Care of the elderly patient
Patients age 65 years or older represent over 30% of acute care hospitalizations and 50% of hospital expenditures. The hospitalized elder is at risk for a multitude of poor outcomes, which may include increased mortality, prolonged length of stay, high rates of readmission, skilled nursing facility placement, and delirium and functional decline. These outcomes have significant medical, psychosocial, and economic impact on individual patients and families as well as on the healthcare system in general. In addition to disease‐based management, care of the elderly must be approached within a specific psychosocial and functional context. Hospitalists engage in a collaborative, multidisciplinary approach to the care of elderly patients that begins at the time of hospital admission and continues through all care transitions. Hospitalists can lead initiatives that improve the care of elderly patients.
KNOWLEDGE
Hospitalists should be able to:
Describe the complications related to hospitalization in the elderly.
Describe the environmental or iatrogenic factors that may contribute to complications in the hospitalized elderly.
List medications with potential to cause adverse drug reactions in the elderly.
Describe interventions that can decrease rates of poor outcomes in the hospitalized elderly.
Explain the key elements of the discharge planning process and options for post‐acute care.
Describe the multiple options for transition from the acute care hospital that can assist patients in regaining functional capacity.
List patient‐specific risk factors for complications in the hospitalized elderly.
SKILLS
Hospitalists should be able to:
Perform a thorough history and physical examination to identify patient risk factors for complications during hospitalization.
Perform a brief cognitive and functional assessment of the elderly patient.
Use active measures to prevent, identify, evaluate and treat pressure ulcers.
Formulate multidisciplinary care plans for the prevention of delirium, falls, and functional decline.
Provide non‐pharmacologic alternatives for the management of agitation, insomnia, and delirium.
Prescribe medications for the behavioral symptoms of delirium or dementia that cannot be controlled with non‐pharmacologic management.
Perform a social assessment of the patient's living conditions/support systems and understand how that impacts the patient's health and care plan.
Formulate safe multidisciplinary plans for care transitions for elderly patients with complex discharge needs.
Incorporate unique characteristics of elderly patients into the development of therapeutic plans.
Recognize signs of potential elder abuse.
ATTITUDES
Hospitalists should be able to:
Appreciate the complications and potential adverse effects associated with polypharmacy.
Educate patients and families about individual measures and community resources that can reduce potential complications after discharge.
Appreciate the risks and complications associated with restraint use.
Appreciate the concept of transitional care.
Participate actively in multidisciplinary team meetings to formulate coordinated care plans for acute hospitalization and care transitions.
Promote a team approach to the care of the hospitalized elder, which may include physicians, nurses, pharmacists, social workers, and rehabilitation services.
Appreciate the medical, psychosocial and economic impact of hospitalization on elderly patients and their families.
Establish and maintain an open dialogue with patients and families regarding care goals and limitations, palliative care, and end of life issues, including living wills.
Connect elderly patients with social services early in the hospital course to provide institutional support, which may include referral for insurance and drug benefits, transportation, mental health services and substance abuse services.
Communicate effectively with primary care physicians and other post‐acute care providers to promote safe, coordinated care transitions.
Lead, coordinate or participate in multidisciplinary hospital initiatives to develop prevention programs and standardized treatment algorithms for elder outcomes such as delirium, falls, functional decline, and pressure ulcers.
Lead, coordinate or participate in hospital initiatives to improve care transitions and reduce poor discharge outcomes in the elderly.
Lead, coordinate or participate in patient safety initiatives to reduce common elder complications in the hospital.
Patients age 65 years or older represent over 30% of acute care hospitalizations and 50% of hospital expenditures. The hospitalized elder is at risk for a multitude of poor outcomes, which may include increased mortality, prolonged length of stay, high rates of readmission, skilled nursing facility placement, and delirium and functional decline. These outcomes have significant medical, psychosocial, and economic impact on individual patients and families as well as on the healthcare system in general. In addition to disease‐based management, care of the elderly must be approached within a specific psychosocial and functional context. Hospitalists engage in a collaborative, multidisciplinary approach to the care of elderly patients that begins at the time of hospital admission and continues through all care transitions. Hospitalists can lead initiatives that improve the care of elderly patients.
KNOWLEDGE
Hospitalists should be able to:
Describe the complications related to hospitalization in the elderly.
Describe the environmental or iatrogenic factors that may contribute to complications in the hospitalized elderly.
List medications with potential to cause adverse drug reactions in the elderly.
Describe interventions that can decrease rates of poor outcomes in the hospitalized elderly.
Explain the key elements of the discharge planning process and options for post‐acute care.
Describe the multiple options for transition from the acute care hospital that can assist patients in regaining functional capacity.
List patient‐specific risk factors for complications in the hospitalized elderly.
SKILLS
Hospitalists should be able to:
Perform a thorough history and physical examination to identify patient risk factors for complications during hospitalization.
Perform a brief cognitive and functional assessment of the elderly patient.
Use active measures to prevent, identify, evaluate and treat pressure ulcers.
Formulate multidisciplinary care plans for the prevention of delirium, falls, and functional decline.
Provide non‐pharmacologic alternatives for the management of agitation, insomnia, and delirium.
Prescribe medications for the behavioral symptoms of delirium or dementia that cannot be controlled with non‐pharmacologic management.
Perform a social assessment of the patient's living conditions/support systems and understand how that impacts the patient's health and care plan.
Formulate safe multidisciplinary plans for care transitions for elderly patients with complex discharge needs.
Incorporate unique characteristics of elderly patients into the development of therapeutic plans.
Recognize signs of potential elder abuse.
ATTITUDES
Hospitalists should be able to:
Appreciate the complications and potential adverse effects associated with polypharmacy.
Educate patients and families about individual measures and community resources that can reduce potential complications after discharge.
Appreciate the risks and complications associated with restraint use.
Appreciate the concept of transitional care.
Participate actively in multidisciplinary team meetings to formulate coordinated care plans for acute hospitalization and care transitions.
Promote a team approach to the care of the hospitalized elder, which may include physicians, nurses, pharmacists, social workers, and rehabilitation services.
Appreciate the medical, psychosocial and economic impact of hospitalization on elderly patients and their families.
Establish and maintain an open dialogue with patients and families regarding care goals and limitations, palliative care, and end of life issues, including living wills.
Connect elderly patients with social services early in the hospital course to provide institutional support, which may include referral for insurance and drug benefits, transportation, mental health services and substance abuse services.
Communicate effectively with primary care physicians and other post‐acute care providers to promote safe, coordinated care transitions.
Lead, coordinate or participate in multidisciplinary hospital initiatives to develop prevention programs and standardized treatment algorithms for elder outcomes such as delirium, falls, functional decline, and pressure ulcers.
Lead, coordinate or participate in hospital initiatives to improve care transitions and reduce poor discharge outcomes in the elderly.
Lead, coordinate or participate in patient safety initiatives to reduce common elder complications in the hospital.
Patients age 65 years or older represent over 30% of acute care hospitalizations and 50% of hospital expenditures. The hospitalized elder is at risk for a multitude of poor outcomes, which may include increased mortality, prolonged length of stay, high rates of readmission, skilled nursing facility placement, and delirium and functional decline. These outcomes have significant medical, psychosocial, and economic impact on individual patients and families as well as on the healthcare system in general. In addition to disease‐based management, care of the elderly must be approached within a specific psychosocial and functional context. Hospitalists engage in a collaborative, multidisciplinary approach to the care of elderly patients that begins at the time of hospital admission and continues through all care transitions. Hospitalists can lead initiatives that improve the care of elderly patients.
KNOWLEDGE
Hospitalists should be able to:
Describe the complications related to hospitalization in the elderly.
Describe the environmental or iatrogenic factors that may contribute to complications in the hospitalized elderly.
List medications with potential to cause adverse drug reactions in the elderly.
Describe interventions that can decrease rates of poor outcomes in the hospitalized elderly.
Explain the key elements of the discharge planning process and options for post‐acute care.
Describe the multiple options for transition from the acute care hospital that can assist patients in regaining functional capacity.
List patient‐specific risk factors for complications in the hospitalized elderly.
SKILLS
Hospitalists should be able to:
Perform a thorough history and physical examination to identify patient risk factors for complications during hospitalization.
Perform a brief cognitive and functional assessment of the elderly patient.
Use active measures to prevent, identify, evaluate and treat pressure ulcers.
Formulate multidisciplinary care plans for the prevention of delirium, falls, and functional decline.
Provide non‐pharmacologic alternatives for the management of agitation, insomnia, and delirium.
Prescribe medications for the behavioral symptoms of delirium or dementia that cannot be controlled with non‐pharmacologic management.
Perform a social assessment of the patient's living conditions/support systems and understand how that impacts the patient's health and care plan.
Formulate safe multidisciplinary plans for care transitions for elderly patients with complex discharge needs.
Incorporate unique characteristics of elderly patients into the development of therapeutic plans.
Recognize signs of potential elder abuse.
ATTITUDES
Hospitalists should be able to:
Appreciate the complications and potential adverse effects associated with polypharmacy.
Educate patients and families about individual measures and community resources that can reduce potential complications after discharge.
Appreciate the risks and complications associated with restraint use.
Appreciate the concept of transitional care.
Participate actively in multidisciplinary team meetings to formulate coordinated care plans for acute hospitalization and care transitions.
Promote a team approach to the care of the hospitalized elder, which may include physicians, nurses, pharmacists, social workers, and rehabilitation services.
Appreciate the medical, psychosocial and economic impact of hospitalization on elderly patients and their families.
Establish and maintain an open dialogue with patients and families regarding care goals and limitations, palliative care, and end of life issues, including living wills.
Connect elderly patients with social services early in the hospital course to provide institutional support, which may include referral for insurance and drug benefits, transportation, mental health services and substance abuse services.
Communicate effectively with primary care physicians and other post‐acute care providers to promote safe, coordinated care transitions.
Lead, coordinate or participate in multidisciplinary hospital initiatives to develop prevention programs and standardized treatment algorithms for elder outcomes such as delirium, falls, functional decline, and pressure ulcers.
Lead, coordinate or participate in hospital initiatives to improve care transitions and reduce poor discharge outcomes in the elderly.
Lead, coordinate or participate in patient safety initiatives to reduce common elder complications in the hospital.
Copyright © 2006 Society of Hospital Medicine
Equitable allocation of resources
Health care expenditures in the United States continue to rise, reaching over $1.4 trillion in 2001 (14% of the gross domestic product), with hospital spending accounting for the largest portion. Hospitals are under constant pressure to provide more efficient care with limited resources. As hospitalists provide cost‐effective inpatient care, they increasingly act as coordinators of care and resources in the hospital setting. Among the factors that make patients vulnerable to inequitable health care are race, ethnicity, and socioeconomic status. While disparity in care exists in United States hospitals, hospitalists are positioned to identify such disparities, optimize care for all patients, and advocate for equitable and cost‐effective allocation of hospital resources.
KNOWLEDGE
Hospitalists should be able to:
Define the concepts of equity and cost‐effectiveness.
Identify patient populations at risk for inequitable health care.
Recognize health resources that are prone to inequitable allocations.
Distinguish between decision analysis, cost‐effectiveness analysis, and cost‐benefit analysis.
Explain how cost‐effectiveness may conflict with equity in health care policies.
Discuss how stereotypes impact the allocation of health resources.
Demonstrate how equity in health care is cost effective.
Illustrate how disparities in health care are related to quality of care.
SKILLS
Hospitalists should be able to:
Measure patient access to hospital resources.
Incorporate equity concerns into cost‐effectiveness analysis.
Triage patients to appropriate hospital resources.
Construct cost‐effective care pathways that allocate resources equitably.
Monitor for equity in health care among hospitalized patients.
Practice evidence based, cost‐effective care for all patients.
ATTITUDES
Hospitalists should be able to:
Listen to the concerns of all patients.
Advocate for every patient's needed health services.
Influence hospital policy to ensure equitable health care coverage for all hospitalized patients.
Act on cultural differences or language barriers during patient encounters that may inhibit equality in health care.
Recognize that over utilization of resources including excessive test ordering may not promote patient safety or patient satisfaction, or improve quality of care.
Lead, coordinate or participate in multidisciplinary teams, which may include radiology, pharmacy, nursing and social services to decrease hospital costs and provide evidence based, cost effective care.
Collaborate with information technologists and health care economists to track utilization and outcomes. Lead, coordinate or participate in quality improvement initiatives to improve resource allocation.
Advocate using cost‐effectiveness analysis, cost benefit analysis, evidence based medicine and measurements of health care equity to mold hospital policy on the allocation of its resources.
Advocate for cross‐cultural education and interpreter services into hospital systems to decrease barriers to equitable health care allocations.
Lead, coordinate, or participate in multidisciplinary hospital and community efforts to ensure proper access to care for all individuals.
Health care expenditures in the United States continue to rise, reaching over $1.4 trillion in 2001 (14% of the gross domestic product), with hospital spending accounting for the largest portion. Hospitals are under constant pressure to provide more efficient care with limited resources. As hospitalists provide cost‐effective inpatient care, they increasingly act as coordinators of care and resources in the hospital setting. Among the factors that make patients vulnerable to inequitable health care are race, ethnicity, and socioeconomic status. While disparity in care exists in United States hospitals, hospitalists are positioned to identify such disparities, optimize care for all patients, and advocate for equitable and cost‐effective allocation of hospital resources.
KNOWLEDGE
Hospitalists should be able to:
Define the concepts of equity and cost‐effectiveness.
Identify patient populations at risk for inequitable health care.
Recognize health resources that are prone to inequitable allocations.
Distinguish between decision analysis, cost‐effectiveness analysis, and cost‐benefit analysis.
Explain how cost‐effectiveness may conflict with equity in health care policies.
Discuss how stereotypes impact the allocation of health resources.
Demonstrate how equity in health care is cost effective.
Illustrate how disparities in health care are related to quality of care.
SKILLS
Hospitalists should be able to:
Measure patient access to hospital resources.
Incorporate equity concerns into cost‐effectiveness analysis.
Triage patients to appropriate hospital resources.
Construct cost‐effective care pathways that allocate resources equitably.
Monitor for equity in health care among hospitalized patients.
Practice evidence based, cost‐effective care for all patients.
ATTITUDES
Hospitalists should be able to:
Listen to the concerns of all patients.
Advocate for every patient's needed health services.
Influence hospital policy to ensure equitable health care coverage for all hospitalized patients.
Act on cultural differences or language barriers during patient encounters that may inhibit equality in health care.
Recognize that over utilization of resources including excessive test ordering may not promote patient safety or patient satisfaction, or improve quality of care.
Lead, coordinate or participate in multidisciplinary teams, which may include radiology, pharmacy, nursing and social services to decrease hospital costs and provide evidence based, cost effective care.
Collaborate with information technologists and health care economists to track utilization and outcomes. Lead, coordinate or participate in quality improvement initiatives to improve resource allocation.
Advocate using cost‐effectiveness analysis, cost benefit analysis, evidence based medicine and measurements of health care equity to mold hospital policy on the allocation of its resources.
Advocate for cross‐cultural education and interpreter services into hospital systems to decrease barriers to equitable health care allocations.
Lead, coordinate, or participate in multidisciplinary hospital and community efforts to ensure proper access to care for all individuals.
Health care expenditures in the United States continue to rise, reaching over $1.4 trillion in 2001 (14% of the gross domestic product), with hospital spending accounting for the largest portion. Hospitals are under constant pressure to provide more efficient care with limited resources. As hospitalists provide cost‐effective inpatient care, they increasingly act as coordinators of care and resources in the hospital setting. Among the factors that make patients vulnerable to inequitable health care are race, ethnicity, and socioeconomic status. While disparity in care exists in United States hospitals, hospitalists are positioned to identify such disparities, optimize care for all patients, and advocate for equitable and cost‐effective allocation of hospital resources.
KNOWLEDGE
Hospitalists should be able to:
Define the concepts of equity and cost‐effectiveness.
Identify patient populations at risk for inequitable health care.
Recognize health resources that are prone to inequitable allocations.
Distinguish between decision analysis, cost‐effectiveness analysis, and cost‐benefit analysis.
Explain how cost‐effectiveness may conflict with equity in health care policies.
Discuss how stereotypes impact the allocation of health resources.
Demonstrate how equity in health care is cost effective.
Illustrate how disparities in health care are related to quality of care.
SKILLS
Hospitalists should be able to:
Measure patient access to hospital resources.
Incorporate equity concerns into cost‐effectiveness analysis.
Triage patients to appropriate hospital resources.
Construct cost‐effective care pathways that allocate resources equitably.
Monitor for equity in health care among hospitalized patients.
Practice evidence based, cost‐effective care for all patients.
ATTITUDES
Hospitalists should be able to:
Listen to the concerns of all patients.
Advocate for every patient's needed health services.
Influence hospital policy to ensure equitable health care coverage for all hospitalized patients.
Act on cultural differences or language barriers during patient encounters that may inhibit equality in health care.
Recognize that over utilization of resources including excessive test ordering may not promote patient safety or patient satisfaction, or improve quality of care.
Lead, coordinate or participate in multidisciplinary teams, which may include radiology, pharmacy, nursing and social services to decrease hospital costs and provide evidence based, cost effective care.
Collaborate with information technologists and health care economists to track utilization and outcomes. Lead, coordinate or participate in quality improvement initiatives to improve resource allocation.
Advocate using cost‐effectiveness analysis, cost benefit analysis, evidence based medicine and measurements of health care equity to mold hospital policy on the allocation of its resources.
Advocate for cross‐cultural education and interpreter services into hospital systems to decrease barriers to equitable health care allocations.
Lead, coordinate, or participate in multidisciplinary hospital and community efforts to ensure proper access to care for all individuals.
Copyright © 2006 Society of Hospital Medicine
Abbreviations
ABG Arterial blood gas
ACLS Advanced cardiac life support
ACS Acute coronary syndrome
ADE Adverse drug event
ARF Acute renal failures
ARR Absolute risk reduction
BLS Basic life support
CAD Coronary artery disease
CAP Community acquired pneumonia
CHF Congestive heart failure
CNS Central nervous system
COPD Chronic obstructive pulmonary disease
CPOE Computer physician order entry
CSF Cerebrospinal fluid
CT Computed tomography
CXR Chest radiograph
DKA Diabetic ketoacidosis
DSM‐IV Diagnostic and Statistical Manual of Mental Disorders (4th edition)
DVT Deep vein thrombosis
EBM Evidence based medicine
EKG Electrocardiogram
FMEA Failure mode and effects analysis
GI Gastrointestinal
HAP Hospital acquired pneumonia
HHS Hyperglycemia hyperosmolar state
ICU Intensive care unit
MRI Magnetic resonance imaging
NNT Number needed to treat
NSAIDS Nonsteroidal anti‐inflammatory drugs
NSTEMI Non‐ST‐segment elevation myocardial infarction
OTC Over‐the‐counter drugs
PBLI Practice based learning and improvement
PE Pulmonary embolus
PDI Pneumonia severity index
PORT Pneumonia patient outcomes research team
PDSA Plan Do Study Act
PSI Pneumonia Severity Index
QI Quality Improvement
RCA Root cause analysis
RRR Relative risk reduction
RVU Relative value units
STEMI ST‐elevation myocardial infarction
SIRS Systemic Inflammatory Response Syndrome
UTI Urinary tract infection
VTE Venous thromboembolism
ABG Arterial blood gas
ACLS Advanced cardiac life support
ACS Acute coronary syndrome
ADE Adverse drug event
ARF Acute renal failures
ARR Absolute risk reduction
BLS Basic life support
CAD Coronary artery disease
CAP Community acquired pneumonia
CHF Congestive heart failure
CNS Central nervous system
COPD Chronic obstructive pulmonary disease
CPOE Computer physician order entry
CSF Cerebrospinal fluid
CT Computed tomography
CXR Chest radiograph
DKA Diabetic ketoacidosis
DSM‐IV Diagnostic and Statistical Manual of Mental Disorders (4th edition)
DVT Deep vein thrombosis
EBM Evidence based medicine
EKG Electrocardiogram
FMEA Failure mode and effects analysis
GI Gastrointestinal
HAP Hospital acquired pneumonia
HHS Hyperglycemia hyperosmolar state
ICU Intensive care unit
MRI Magnetic resonance imaging
NNT Number needed to treat
NSAIDS Nonsteroidal anti‐inflammatory drugs
NSTEMI Non‐ST‐segment elevation myocardial infarction
OTC Over‐the‐counter drugs
PBLI Practice based learning and improvement
PE Pulmonary embolus
PDI Pneumonia severity index
PORT Pneumonia patient outcomes research team
PDSA Plan Do Study Act
PSI Pneumonia Severity Index
QI Quality Improvement
RCA Root cause analysis
RRR Relative risk reduction
RVU Relative value units
STEMI ST‐elevation myocardial infarction
SIRS Systemic Inflammatory Response Syndrome
UTI Urinary tract infection
VTE Venous thromboembolism
ABG Arterial blood gas
ACLS Advanced cardiac life support
ACS Acute coronary syndrome
ADE Adverse drug event
ARF Acute renal failures
ARR Absolute risk reduction
BLS Basic life support
CAD Coronary artery disease
CAP Community acquired pneumonia
CHF Congestive heart failure
CNS Central nervous system
COPD Chronic obstructive pulmonary disease
CPOE Computer physician order entry
CSF Cerebrospinal fluid
CT Computed tomography
CXR Chest radiograph
DKA Diabetic ketoacidosis
DSM‐IV Diagnostic and Statistical Manual of Mental Disorders (4th edition)
DVT Deep vein thrombosis
EBM Evidence based medicine
EKG Electrocardiogram
FMEA Failure mode and effects analysis
GI Gastrointestinal
HAP Hospital acquired pneumonia
HHS Hyperglycemia hyperosmolar state
ICU Intensive care unit
MRI Magnetic resonance imaging
NNT Number needed to treat
NSAIDS Nonsteroidal anti‐inflammatory drugs
NSTEMI Non‐ST‐segment elevation myocardial infarction
OTC Over‐the‐counter drugs
PBLI Practice based learning and improvement
PE Pulmonary embolus
PDI Pneumonia severity index
PORT Pneumonia patient outcomes research team
PDSA Plan Do Study Act
PSI Pneumonia Severity Index
QI Quality Improvement
RCA Root cause analysis
RRR Relative risk reduction
RVU Relative value units
STEMI ST‐elevation myocardial infarction
SIRS Systemic Inflammatory Response Syndrome
UTI Urinary tract infection
VTE Venous thromboembolism
Copyright © 2006 Society of Hospital Medicine
Emergency procedures
In Hospital Medicine, emergency procedures refer to advanced cardiac life support (ACLS), endotracheal intubation, and short‐term mechanical ventilation. Hospitalists care for patients admitted to the hospital with critical illnesses, as well as patients who have become critically ill during their hospital stay. In providing care to patients who have become critically ill, many Hospitalists perform or supervise these emergency procedures. Hospitalists lead efforts to provide timely, standardized response to inpatient emergencies.
CARDIOPULMONARY RESUSCITATION
KNOWLEDGE
Hospitalists should be able to:
Describe the normal anatomy of the oral cavity, airway, thorax, heart and lungs.
Describe the clinical findings or disease processes that require implementation of cardiopulmonary resuscitation and advanced life support.
Describe clinical or cardiac rhythm findings that may impact outcomes for patients with cardiopulmonary arrest.
List the laboratory and other diagnostic tests indicated during cardiopulmonary distress or arrest and immediately following successful resuscitation.
Explain basic life support (BLS) protocols.
Explain and differentiate current ACLS protocols, including the indicated interventions, based on the clinical situation and cardiac rhythm.
Select the necessary equipment to manage the airway, identify cardiac rhythms, and perform defibrillation.
Explain which cardiac rhythms and clinical situations require immediate defibrillation.
Explain the mechanisms of action and uses of medications employed during ACLS.
Explain the indications for procedural interventions that may be employed during the course of resuscitation.
Explain the role of hyperthermia as a neuro‐protective measure in the post‐resuscitation period.
SKILLS
Hospitalists should be able to:
Promptly identify acute cardiopulmonary distress or arrest, and call for assistance.
Assess the patient, rapidly review the situation, and develop a differential diagnosis of etiology.
Elicit additional history from the patient's family, other healthcare providers, and the patient's chart when available.
Clearly and rapidly identify the event leader, and delineate other staff roles at the beginning of the resuscitation event.
Properly position the patient on a backboard to perform BLS and ACLS protocols.
Continually reassess proper patient positioning during resuscitation.
Perform BLS protocols to open the airway, use a bag‐valve‐mask ventilatory device, and perform external chest compressions.
Attach a defibrillator/pacer pads to the patient, and explain the operation of manual and automated defibrillators and external pacing systems.
Maintain clinician safety with appropriate protective wear.
Interpret cardiac rhythms and other diagnostic indicators.
Synthesize diagnostic information to deliver medications and/or defibrillation, and perform procedures required during resuscitation efforts.
ATTITUDES
Hospitalists should be able to:
Assess and respect the wishes of patients and families who desire no or limited resuscitation measures during hospitalization.
Communicate with families to explain the efforts performed as well as outcomes and next steps.
Rapidly respond to emergencies without distraction.
Facilitate interactions between healthcare professionals about the roles that each will perform during the resuscitation effort.
Review the resuscitation documentation for accuracy immediately following the event.
Recognize the indications for emergent specialty consultation when available, which may include ENT, surgery, or critical care medicine.
Appreciate the value of spiritual support services during and following resuscitation efforts.
Discontinue resuscitation efforts when interventions have been unsuccessful and continued efforts are medically futile.
Arrange for appropriate care transitions following successful resuscitation.
Address family wishes regarding organ donation and autopsy.
ENDOTRACHEAL INTUBATION
KNOWLEDGE
Hospitalists should be able to:
Describe the anatomy of the oral cavity, posterior pharynx and larynx.
Describe clinical findings or disease processes that may require securing an airway.
Describe the indications and contraindications, benefits and risks of endotracheal intubation.
Describe the necessary equipment and medications required for routine and difficult intubations.
Describe the process of endotracheal intubation from laryngoscope assembly to assessment of tube placement.
Describe and differentiate alternatives to endotracheal intubation.
SKILLS
Hospitalists should be able to:
Identify patients for whom endotracheal intubation may be required.
Utilize bag‐valve‐mask ventilation with oral or nasal airway as a bridge to intubation.
Select the appropriate laryngoscope blade for the individual patient.
Position the patient and the bed for optimal procedure success and operator comfort.
Assemble the laryngoscope and intubate the patient after visualizing the vocal cords.
Prepare the oropharynx for intubation using necessary steps that may include removal of oral hardware, suctioning, and application of cricoid pressure.
Request cricoid pressure and other maneuvers when indicated.
Place the endotracheal tube at an appropriate depth in the airway.
Confirm endotracheal tube placement by gastric and breath sounds, carbon dioxide monitor, and radiography; adjust tube position when indicated.
ATTITUDES
Hospitalists should be able to:
Communicate with patients and families regarding procedure indications and next steps in management.
Maintain high oxygen saturation prior to intubation whenever possible.
Minimize patient trauma risk during intubations.
Appreciate that bag‐valve‐mask can provide adequate oxygenation for extended periods when difficult intubations are delayed.
Maintain clinician safety with appropriate protective wear.
Use an alternative airway control device (e.g. laryngeal mask airway) for patients with difficult or unsuccessful intubations.
Request appropriate specialist consultation for difficult or unsuccessful intubations or when clinician experience level precludes intubation trial.
MECHANICAL VENTILATION
KNOWLEDGE
Hospitalists should be able to:
Describe the normal anatomy of the chest wall, thorax, and lung.
Describe disease processes that lead to respiratory failure and expected clinical findings.
Describe the indications, benefits and risks of mechanical ventilation.
Describe indications and contraindications for non‐invasive ventilation in selected patients.
Explain the role of arterial blood gas (ABG) analysis in the management of ventilated patients.
Describe available modes of ventilation, and how to select initial and subsequent ventilator settings.
Describe methods of and indications for sedation, comfort management, and/or paralysis in ventilated patients.
Describe various ventilator settings and explain the use of individual settings based on the patient's disease process and clinical condition.
SKILLS
Hospitalists should be able to:
Utilize nursing and respiratory therapy reports, physical examination, and ventilator data to identify complications due to mechanical ventilation.
Select and adjust the ventilator mode and settings based on underlying disease process, other patient factors, ventilator data, and ABG analysis.
Employ indicated interventions when complications of mechanical ventilation are identified.
Identify the components of the ventilator, assess proper functioning, and identify equipment malfunction and/or patient‐ventilator dysynchrony.
Order and interpret laboratory and imaging studies based on changes in patient's clinical status.
Order adequate sedation and other indicated interventions to treat underlying conditions leading to respiratory failure and to prevent the complications of mechanical ventilation.
ATTITUDES
Hospitalists should be able to:
Communicate with patients and/or families to explain the risks, benefits, and alternatives to invasive ventilation.
Obtain informed consent prior to non‐emergent intubations.
Conduct regular family meetings to provide clinical updates and facilitate shared decision‐making.
Implement interventions shown to reduce risk of ventilator‐associated complications, which may include hospital acquired pneumonia, stress ulceration and bleeding, and venous thromboembolism.
Provide adequate sedation, comfort management, and paralysis when indicated for patients requiring mechanical ventilation.
Recognize the indications for specialty consultation, which may include critical care medicine.
SYSTEM ORGANIZATION AND IMPROVEMENT FOR EMERGENCY PROCEDURES
To improve efficiency and quality within their organizations, Hospitalists should:
Collaborate with critical care physicians, respiratory therapists, and critical care nurses to develop evidence based protocols or guidelines for optimal ventilator management and weaning.
Lead, coordinate or participate in evaluation of resuscitation and mechanical ventilation outcomes and identify and implement improvement initiatives.
Lead, coordinate or participate in multidisciplinary teams, which may include critical care nurses, respiratory therapists, and critical care and emergency physicians, to establish ongoing training to ensure high quality performance of emergency procedures.
Lead, coordinate or participate in multidisciplinary efforts to review antecedent events to identify changes in clinical status which, if promptly identified and acted upon, may have prevented the emergency intervention.
Facilitate appropriate organization and consolidation of equipment in multiple identifiable and accessible locations in the hospital for performance of emergency procedures.
In Hospital Medicine, emergency procedures refer to advanced cardiac life support (ACLS), endotracheal intubation, and short‐term mechanical ventilation. Hospitalists care for patients admitted to the hospital with critical illnesses, as well as patients who have become critically ill during their hospital stay. In providing care to patients who have become critically ill, many Hospitalists perform or supervise these emergency procedures. Hospitalists lead efforts to provide timely, standardized response to inpatient emergencies.
CARDIOPULMONARY RESUSCITATION
KNOWLEDGE
Hospitalists should be able to:
Describe the normal anatomy of the oral cavity, airway, thorax, heart and lungs.
Describe the clinical findings or disease processes that require implementation of cardiopulmonary resuscitation and advanced life support.
Describe clinical or cardiac rhythm findings that may impact outcomes for patients with cardiopulmonary arrest.
List the laboratory and other diagnostic tests indicated during cardiopulmonary distress or arrest and immediately following successful resuscitation.
Explain basic life support (BLS) protocols.
Explain and differentiate current ACLS protocols, including the indicated interventions, based on the clinical situation and cardiac rhythm.
Select the necessary equipment to manage the airway, identify cardiac rhythms, and perform defibrillation.
Explain which cardiac rhythms and clinical situations require immediate defibrillation.
Explain the mechanisms of action and uses of medications employed during ACLS.
Explain the indications for procedural interventions that may be employed during the course of resuscitation.
Explain the role of hyperthermia as a neuro‐protective measure in the post‐resuscitation period.
SKILLS
Hospitalists should be able to:
Promptly identify acute cardiopulmonary distress or arrest, and call for assistance.
Assess the patient, rapidly review the situation, and develop a differential diagnosis of etiology.
Elicit additional history from the patient's family, other healthcare providers, and the patient's chart when available.
Clearly and rapidly identify the event leader, and delineate other staff roles at the beginning of the resuscitation event.
Properly position the patient on a backboard to perform BLS and ACLS protocols.
Continually reassess proper patient positioning during resuscitation.
Perform BLS protocols to open the airway, use a bag‐valve‐mask ventilatory device, and perform external chest compressions.
Attach a defibrillator/pacer pads to the patient, and explain the operation of manual and automated defibrillators and external pacing systems.
Maintain clinician safety with appropriate protective wear.
Interpret cardiac rhythms and other diagnostic indicators.
Synthesize diagnostic information to deliver medications and/or defibrillation, and perform procedures required during resuscitation efforts.
ATTITUDES
Hospitalists should be able to:
Assess and respect the wishes of patients and families who desire no or limited resuscitation measures during hospitalization.
Communicate with families to explain the efforts performed as well as outcomes and next steps.
Rapidly respond to emergencies without distraction.
Facilitate interactions between healthcare professionals about the roles that each will perform during the resuscitation effort.
Review the resuscitation documentation for accuracy immediately following the event.
Recognize the indications for emergent specialty consultation when available, which may include ENT, surgery, or critical care medicine.
Appreciate the value of spiritual support services during and following resuscitation efforts.
Discontinue resuscitation efforts when interventions have been unsuccessful and continued efforts are medically futile.
Arrange for appropriate care transitions following successful resuscitation.
Address family wishes regarding organ donation and autopsy.
ENDOTRACHEAL INTUBATION
KNOWLEDGE
Hospitalists should be able to:
Describe the anatomy of the oral cavity, posterior pharynx and larynx.
Describe clinical findings or disease processes that may require securing an airway.
Describe the indications and contraindications, benefits and risks of endotracheal intubation.
Describe the necessary equipment and medications required for routine and difficult intubations.
Describe the process of endotracheal intubation from laryngoscope assembly to assessment of tube placement.
Describe and differentiate alternatives to endotracheal intubation.
SKILLS
Hospitalists should be able to:
Identify patients for whom endotracheal intubation may be required.
Utilize bag‐valve‐mask ventilation with oral or nasal airway as a bridge to intubation.
Select the appropriate laryngoscope blade for the individual patient.
Position the patient and the bed for optimal procedure success and operator comfort.
Assemble the laryngoscope and intubate the patient after visualizing the vocal cords.
Prepare the oropharynx for intubation using necessary steps that may include removal of oral hardware, suctioning, and application of cricoid pressure.
Request cricoid pressure and other maneuvers when indicated.
Place the endotracheal tube at an appropriate depth in the airway.
Confirm endotracheal tube placement by gastric and breath sounds, carbon dioxide monitor, and radiography; adjust tube position when indicated.
ATTITUDES
Hospitalists should be able to:
Communicate with patients and families regarding procedure indications and next steps in management.
Maintain high oxygen saturation prior to intubation whenever possible.
Minimize patient trauma risk during intubations.
Appreciate that bag‐valve‐mask can provide adequate oxygenation for extended periods when difficult intubations are delayed.
Maintain clinician safety with appropriate protective wear.
Use an alternative airway control device (e.g. laryngeal mask airway) for patients with difficult or unsuccessful intubations.
Request appropriate specialist consultation for difficult or unsuccessful intubations or when clinician experience level precludes intubation trial.
MECHANICAL VENTILATION
KNOWLEDGE
Hospitalists should be able to:
Describe the normal anatomy of the chest wall, thorax, and lung.
Describe disease processes that lead to respiratory failure and expected clinical findings.
Describe the indications, benefits and risks of mechanical ventilation.
Describe indications and contraindications for non‐invasive ventilation in selected patients.
Explain the role of arterial blood gas (ABG) analysis in the management of ventilated patients.
Describe available modes of ventilation, and how to select initial and subsequent ventilator settings.
Describe methods of and indications for sedation, comfort management, and/or paralysis in ventilated patients.
Describe various ventilator settings and explain the use of individual settings based on the patient's disease process and clinical condition.
SKILLS
Hospitalists should be able to:
Utilize nursing and respiratory therapy reports, physical examination, and ventilator data to identify complications due to mechanical ventilation.
Select and adjust the ventilator mode and settings based on underlying disease process, other patient factors, ventilator data, and ABG analysis.
Employ indicated interventions when complications of mechanical ventilation are identified.
Identify the components of the ventilator, assess proper functioning, and identify equipment malfunction and/or patient‐ventilator dysynchrony.
Order and interpret laboratory and imaging studies based on changes in patient's clinical status.
Order adequate sedation and other indicated interventions to treat underlying conditions leading to respiratory failure and to prevent the complications of mechanical ventilation.
ATTITUDES
Hospitalists should be able to:
Communicate with patients and/or families to explain the risks, benefits, and alternatives to invasive ventilation.
Obtain informed consent prior to non‐emergent intubations.
Conduct regular family meetings to provide clinical updates and facilitate shared decision‐making.
Implement interventions shown to reduce risk of ventilator‐associated complications, which may include hospital acquired pneumonia, stress ulceration and bleeding, and venous thromboembolism.
Provide adequate sedation, comfort management, and paralysis when indicated for patients requiring mechanical ventilation.
Recognize the indications for specialty consultation, which may include critical care medicine.
SYSTEM ORGANIZATION AND IMPROVEMENT FOR EMERGENCY PROCEDURES
To improve efficiency and quality within their organizations, Hospitalists should:
Collaborate with critical care physicians, respiratory therapists, and critical care nurses to develop evidence based protocols or guidelines for optimal ventilator management and weaning.
Lead, coordinate or participate in evaluation of resuscitation and mechanical ventilation outcomes and identify and implement improvement initiatives.
Lead, coordinate or participate in multidisciplinary teams, which may include critical care nurses, respiratory therapists, and critical care and emergency physicians, to establish ongoing training to ensure high quality performance of emergency procedures.
Lead, coordinate or participate in multidisciplinary efforts to review antecedent events to identify changes in clinical status which, if promptly identified and acted upon, may have prevented the emergency intervention.
Facilitate appropriate organization and consolidation of equipment in multiple identifiable and accessible locations in the hospital for performance of emergency procedures.
In Hospital Medicine, emergency procedures refer to advanced cardiac life support (ACLS), endotracheal intubation, and short‐term mechanical ventilation. Hospitalists care for patients admitted to the hospital with critical illnesses, as well as patients who have become critically ill during their hospital stay. In providing care to patients who have become critically ill, many Hospitalists perform or supervise these emergency procedures. Hospitalists lead efforts to provide timely, standardized response to inpatient emergencies.
CARDIOPULMONARY RESUSCITATION
KNOWLEDGE
Hospitalists should be able to:
Describe the normal anatomy of the oral cavity, airway, thorax, heart and lungs.
Describe the clinical findings or disease processes that require implementation of cardiopulmonary resuscitation and advanced life support.
Describe clinical or cardiac rhythm findings that may impact outcomes for patients with cardiopulmonary arrest.
List the laboratory and other diagnostic tests indicated during cardiopulmonary distress or arrest and immediately following successful resuscitation.
Explain basic life support (BLS) protocols.
Explain and differentiate current ACLS protocols, including the indicated interventions, based on the clinical situation and cardiac rhythm.
Select the necessary equipment to manage the airway, identify cardiac rhythms, and perform defibrillation.
Explain which cardiac rhythms and clinical situations require immediate defibrillation.
Explain the mechanisms of action and uses of medications employed during ACLS.
Explain the indications for procedural interventions that may be employed during the course of resuscitation.
Explain the role of hyperthermia as a neuro‐protective measure in the post‐resuscitation period.
SKILLS
Hospitalists should be able to:
Promptly identify acute cardiopulmonary distress or arrest, and call for assistance.
Assess the patient, rapidly review the situation, and develop a differential diagnosis of etiology.
Elicit additional history from the patient's family, other healthcare providers, and the patient's chart when available.
Clearly and rapidly identify the event leader, and delineate other staff roles at the beginning of the resuscitation event.
Properly position the patient on a backboard to perform BLS and ACLS protocols.
Continually reassess proper patient positioning during resuscitation.
Perform BLS protocols to open the airway, use a bag‐valve‐mask ventilatory device, and perform external chest compressions.
Attach a defibrillator/pacer pads to the patient, and explain the operation of manual and automated defibrillators and external pacing systems.
Maintain clinician safety with appropriate protective wear.
Interpret cardiac rhythms and other diagnostic indicators.
Synthesize diagnostic information to deliver medications and/or defibrillation, and perform procedures required during resuscitation efforts.
ATTITUDES
Hospitalists should be able to:
Assess and respect the wishes of patients and families who desire no or limited resuscitation measures during hospitalization.
Communicate with families to explain the efforts performed as well as outcomes and next steps.
Rapidly respond to emergencies without distraction.
Facilitate interactions between healthcare professionals about the roles that each will perform during the resuscitation effort.
Review the resuscitation documentation for accuracy immediately following the event.
Recognize the indications for emergent specialty consultation when available, which may include ENT, surgery, or critical care medicine.
Appreciate the value of spiritual support services during and following resuscitation efforts.
Discontinue resuscitation efforts when interventions have been unsuccessful and continued efforts are medically futile.
Arrange for appropriate care transitions following successful resuscitation.
Address family wishes regarding organ donation and autopsy.
ENDOTRACHEAL INTUBATION
KNOWLEDGE
Hospitalists should be able to:
Describe the anatomy of the oral cavity, posterior pharynx and larynx.
Describe clinical findings or disease processes that may require securing an airway.
Describe the indications and contraindications, benefits and risks of endotracheal intubation.
Describe the necessary equipment and medications required for routine and difficult intubations.
Describe the process of endotracheal intubation from laryngoscope assembly to assessment of tube placement.
Describe and differentiate alternatives to endotracheal intubation.
SKILLS
Hospitalists should be able to:
Identify patients for whom endotracheal intubation may be required.
Utilize bag‐valve‐mask ventilation with oral or nasal airway as a bridge to intubation.
Select the appropriate laryngoscope blade for the individual patient.
Position the patient and the bed for optimal procedure success and operator comfort.
Assemble the laryngoscope and intubate the patient after visualizing the vocal cords.
Prepare the oropharynx for intubation using necessary steps that may include removal of oral hardware, suctioning, and application of cricoid pressure.
Request cricoid pressure and other maneuvers when indicated.
Place the endotracheal tube at an appropriate depth in the airway.
Confirm endotracheal tube placement by gastric and breath sounds, carbon dioxide monitor, and radiography; adjust tube position when indicated.
ATTITUDES
Hospitalists should be able to:
Communicate with patients and families regarding procedure indications and next steps in management.
Maintain high oxygen saturation prior to intubation whenever possible.
Minimize patient trauma risk during intubations.
Appreciate that bag‐valve‐mask can provide adequate oxygenation for extended periods when difficult intubations are delayed.
Maintain clinician safety with appropriate protective wear.
Use an alternative airway control device (e.g. laryngeal mask airway) for patients with difficult or unsuccessful intubations.
Request appropriate specialist consultation for difficult or unsuccessful intubations or when clinician experience level precludes intubation trial.
MECHANICAL VENTILATION
KNOWLEDGE
Hospitalists should be able to:
Describe the normal anatomy of the chest wall, thorax, and lung.
Describe disease processes that lead to respiratory failure and expected clinical findings.
Describe the indications, benefits and risks of mechanical ventilation.
Describe indications and contraindications for non‐invasive ventilation in selected patients.
Explain the role of arterial blood gas (ABG) analysis in the management of ventilated patients.
Describe available modes of ventilation, and how to select initial and subsequent ventilator settings.
Describe methods of and indications for sedation, comfort management, and/or paralysis in ventilated patients.
Describe various ventilator settings and explain the use of individual settings based on the patient's disease process and clinical condition.
SKILLS
Hospitalists should be able to:
Utilize nursing and respiratory therapy reports, physical examination, and ventilator data to identify complications due to mechanical ventilation.
Select and adjust the ventilator mode and settings based on underlying disease process, other patient factors, ventilator data, and ABG analysis.
Employ indicated interventions when complications of mechanical ventilation are identified.
Identify the components of the ventilator, assess proper functioning, and identify equipment malfunction and/or patient‐ventilator dysynchrony.
Order and interpret laboratory and imaging studies based on changes in patient's clinical status.
Order adequate sedation and other indicated interventions to treat underlying conditions leading to respiratory failure and to prevent the complications of mechanical ventilation.
ATTITUDES
Hospitalists should be able to:
Communicate with patients and/or families to explain the risks, benefits, and alternatives to invasive ventilation.
Obtain informed consent prior to non‐emergent intubations.
Conduct regular family meetings to provide clinical updates and facilitate shared decision‐making.
Implement interventions shown to reduce risk of ventilator‐associated complications, which may include hospital acquired pneumonia, stress ulceration and bleeding, and venous thromboembolism.
Provide adequate sedation, comfort management, and paralysis when indicated for patients requiring mechanical ventilation.
Recognize the indications for specialty consultation, which may include critical care medicine.
SYSTEM ORGANIZATION AND IMPROVEMENT FOR EMERGENCY PROCEDURES
To improve efficiency and quality within their organizations, Hospitalists should:
Collaborate with critical care physicians, respiratory therapists, and critical care nurses to develop evidence based protocols or guidelines for optimal ventilator management and weaning.
Lead, coordinate or participate in evaluation of resuscitation and mechanical ventilation outcomes and identify and implement improvement initiatives.
Lead, coordinate or participate in multidisciplinary teams, which may include critical care nurses, respiratory therapists, and critical care and emergency physicians, to establish ongoing training to ensure high quality performance of emergency procedures.
Lead, coordinate or participate in multidisciplinary efforts to review antecedent events to identify changes in clinical status which, if promptly identified and acted upon, may have prevented the emergency intervention.
Facilitate appropriate organization and consolidation of equipment in multiple identifiable and accessible locations in the hospital for performance of emergency procedures.
Copyright © 2006 Society of Hospital Medicine
Prevention of healthcare‐associated infections and antimicrobial resistance
Healthcare‐associated infections impose a significant burden on the healthcare system in the Unites States, both economically and in terms of patient outcomes. The Centers for Disease Control and Prevention (CDC) estimate that nearly 2 million patients develop healthcare‐associated infections each year, and approximately 88,000 die as a direct or indirect result of their infections. These infections often lead to increases in length of hospitalization, and result in about $4.5 billion in excess costs annually. The central aim of infection control is to prevent healthcare‐associated infections and the emergence of resistant organisms. Hospitalists work in concert with other members of the healthcare organization to reduce healthcare‐associated infections, develop institutional initiatives for prevention, and promote and implement evidence based infection control measures.
KNOWLEDGE
Hospitalists should be able to:
Describe acceptable methods of hand hygiene technique and timing in relationship to patient contact.
Describe the prophylactic measures required for all types of isolation precautions, which include Standard, Contact, Droplet, and Airborne Precautions, and list the indications for implementing each type of precaution.
List common types of healthcare‐associated infections, and describe the risk factors associated with urinary tract infections, surgical site infections, hospital‐acquired pneumonia, and blood stream infections.
Explain the utility of the hospital antibiogram in delineating antimicrobial resistance patterns for bacterial isolates, and how it should be used to make empiric antibiotic selections.
Identify major resources for infection control information, including hospital infection control staff, hospital infection control policies and procedures, local and state public health departments, and CDCP guidelines.
Describe the indicated prevention measures necessary to perform hospital‐based procedures in a sterile fashion.
SKILLS
Hospitalists should be able to:
Perform consistent and optimal hand hygiene techniques at all indicated points of care.
Implement indicated isolation precautions for patients with high risk transmissible diseases or highly resistant infections.
Identify and utilize local hospital resources, including antibiograms and infection control officers.
Perform indicated infection control and prevention technique during all procedures.
Implement precautions and infection control practices to protect patients from acquiring healthcare‐associated infections.
ATTITUDES
Hospitalists should be able to:
Appreciate that specific infection control practices and engineering controls are required to protect very high risk patient populations, which may include hematopoietic stem cell transplant or solid organ transplant recipients, from healthcare associated infections.
Serve as a role model in adherence to recommended hand hygiene and infection control practices.
Communicate effectively the rationale and importance of infection control practices to patients, families, visitors, other health care providers and hospital staff.
Communicate appropriate patient information to infection control staff regarding potentially transmissible diseases.
Avoid devices that are more likely to cause hospital‐acquired infections if alternatives are safe, effective and available.
Encourage removal of invasive devices, especially central venous catheters and urinary catheters, early during hospital stay and as soon as clinically safe to do so.
Collaborate with multidisciplinary teams, which may include infection control, nursing service, and infectious disease consultants, to rapidly implement and maintain isolation precautions.
Collaborate with multidisciplinary teams that may include infection control, nursing service, care coordination, long term care facilities, home health care staff, and public health personnel to plan for hospital discharge of patients with transmissible infectious diseases.
Lead, coordinate or participate in efforts to educate other health care personnel and hospital staff about necessary infection control prevention measures.
Lead, coordinate or participate in multidisciplinary teams that organize, implement, and study infection control protocols, guidelines or pathways, using evidence based systematic methods.
Lead, coordinate or participate in multidisciplinary efforts to develop empiric antibiotic regimens to minimize the development of resistance within a particular hospital or region.
Healthcare‐associated infections impose a significant burden on the healthcare system in the Unites States, both economically and in terms of patient outcomes. The Centers for Disease Control and Prevention (CDC) estimate that nearly 2 million patients develop healthcare‐associated infections each year, and approximately 88,000 die as a direct or indirect result of their infections. These infections often lead to increases in length of hospitalization, and result in about $4.5 billion in excess costs annually. The central aim of infection control is to prevent healthcare‐associated infections and the emergence of resistant organisms. Hospitalists work in concert with other members of the healthcare organization to reduce healthcare‐associated infections, develop institutional initiatives for prevention, and promote and implement evidence based infection control measures.
KNOWLEDGE
Hospitalists should be able to:
Describe acceptable methods of hand hygiene technique and timing in relationship to patient contact.
Describe the prophylactic measures required for all types of isolation precautions, which include Standard, Contact, Droplet, and Airborne Precautions, and list the indications for implementing each type of precaution.
List common types of healthcare‐associated infections, and describe the risk factors associated with urinary tract infections, surgical site infections, hospital‐acquired pneumonia, and blood stream infections.
Explain the utility of the hospital antibiogram in delineating antimicrobial resistance patterns for bacterial isolates, and how it should be used to make empiric antibiotic selections.
Identify major resources for infection control information, including hospital infection control staff, hospital infection control policies and procedures, local and state public health departments, and CDCP guidelines.
Describe the indicated prevention measures necessary to perform hospital‐based procedures in a sterile fashion.
SKILLS
Hospitalists should be able to:
Perform consistent and optimal hand hygiene techniques at all indicated points of care.
Implement indicated isolation precautions for patients with high risk transmissible diseases or highly resistant infections.
Identify and utilize local hospital resources, including antibiograms and infection control officers.
Perform indicated infection control and prevention technique during all procedures.
Implement precautions and infection control practices to protect patients from acquiring healthcare‐associated infections.
ATTITUDES
Hospitalists should be able to:
Appreciate that specific infection control practices and engineering controls are required to protect very high risk patient populations, which may include hematopoietic stem cell transplant or solid organ transplant recipients, from healthcare associated infections.
Serve as a role model in adherence to recommended hand hygiene and infection control practices.
Communicate effectively the rationale and importance of infection control practices to patients, families, visitors, other health care providers and hospital staff.
Communicate appropriate patient information to infection control staff regarding potentially transmissible diseases.
Avoid devices that are more likely to cause hospital‐acquired infections if alternatives are safe, effective and available.
Encourage removal of invasive devices, especially central venous catheters and urinary catheters, early during hospital stay and as soon as clinically safe to do so.
Collaborate with multidisciplinary teams, which may include infection control, nursing service, and infectious disease consultants, to rapidly implement and maintain isolation precautions.
Collaborate with multidisciplinary teams that may include infection control, nursing service, care coordination, long term care facilities, home health care staff, and public health personnel to plan for hospital discharge of patients with transmissible infectious diseases.
Lead, coordinate or participate in efforts to educate other health care personnel and hospital staff about necessary infection control prevention measures.
Lead, coordinate or participate in multidisciplinary teams that organize, implement, and study infection control protocols, guidelines or pathways, using evidence based systematic methods.
Lead, coordinate or participate in multidisciplinary efforts to develop empiric antibiotic regimens to minimize the development of resistance within a particular hospital or region.
Healthcare‐associated infections impose a significant burden on the healthcare system in the Unites States, both economically and in terms of patient outcomes. The Centers for Disease Control and Prevention (CDC) estimate that nearly 2 million patients develop healthcare‐associated infections each year, and approximately 88,000 die as a direct or indirect result of their infections. These infections often lead to increases in length of hospitalization, and result in about $4.5 billion in excess costs annually. The central aim of infection control is to prevent healthcare‐associated infections and the emergence of resistant organisms. Hospitalists work in concert with other members of the healthcare organization to reduce healthcare‐associated infections, develop institutional initiatives for prevention, and promote and implement evidence based infection control measures.
KNOWLEDGE
Hospitalists should be able to:
Describe acceptable methods of hand hygiene technique and timing in relationship to patient contact.
Describe the prophylactic measures required for all types of isolation precautions, which include Standard, Contact, Droplet, and Airborne Precautions, and list the indications for implementing each type of precaution.
List common types of healthcare‐associated infections, and describe the risk factors associated with urinary tract infections, surgical site infections, hospital‐acquired pneumonia, and blood stream infections.
Explain the utility of the hospital antibiogram in delineating antimicrobial resistance patterns for bacterial isolates, and how it should be used to make empiric antibiotic selections.
Identify major resources for infection control information, including hospital infection control staff, hospital infection control policies and procedures, local and state public health departments, and CDCP guidelines.
Describe the indicated prevention measures necessary to perform hospital‐based procedures in a sterile fashion.
SKILLS
Hospitalists should be able to:
Perform consistent and optimal hand hygiene techniques at all indicated points of care.
Implement indicated isolation precautions for patients with high risk transmissible diseases or highly resistant infections.
Identify and utilize local hospital resources, including antibiograms and infection control officers.
Perform indicated infection control and prevention technique during all procedures.
Implement precautions and infection control practices to protect patients from acquiring healthcare‐associated infections.
ATTITUDES
Hospitalists should be able to:
Appreciate that specific infection control practices and engineering controls are required to protect very high risk patient populations, which may include hematopoietic stem cell transplant or solid organ transplant recipients, from healthcare associated infections.
Serve as a role model in adherence to recommended hand hygiene and infection control practices.
Communicate effectively the rationale and importance of infection control practices to patients, families, visitors, other health care providers and hospital staff.
Communicate appropriate patient information to infection control staff regarding potentially transmissible diseases.
Avoid devices that are more likely to cause hospital‐acquired infections if alternatives are safe, effective and available.
Encourage removal of invasive devices, especially central venous catheters and urinary catheters, early during hospital stay and as soon as clinically safe to do so.
Collaborate with multidisciplinary teams, which may include infection control, nursing service, and infectious disease consultants, to rapidly implement and maintain isolation precautions.
Collaborate with multidisciplinary teams that may include infection control, nursing service, care coordination, long term care facilities, home health care staff, and public health personnel to plan for hospital discharge of patients with transmissible infectious diseases.
Lead, coordinate or participate in efforts to educate other health care personnel and hospital staff about necessary infection control prevention measures.
Lead, coordinate or participate in multidisciplinary teams that organize, implement, and study infection control protocols, guidelines or pathways, using evidence based systematic methods.
Lead, coordinate or participate in multidisciplinary efforts to develop empiric antibiotic regimens to minimize the development of resistance within a particular hospital or region.
Copyright © 2006 Society of Hospital Medicine
Diabetes mellitus
Diabetes mellitus is a disease characterized by abnormal insulin production or disordered glucose metabolism and is a co‐morbid condition of many hospitalized patients. diabetic ketoacidosis (dka) and hyperglycemia hyperosmolar state (hhs) are extreme presentations of diabetes mellitus that require hospitalization. there were 577,000 hospital discharges for diabetes mellitus in 2002, according to the american heart association. the prevalence of physician‐diagnosed diabetes mellitus was 13.9 million or 6.7 percent of the united states population. another 5.9 million americans are believed to have undiagnosed diabetes mellitus. the healthcare cost and utilization project (hcup) reports an average length‐of‐stay of 4.1 days and mean charges of $11,761 per patient for the diagnosis related group (drg) for diabetes mellitus. the estimated economic cost of diabetes in 2002 was $132 billion, of which $92 billion was direct medical costs. hospitalists care for diabetic patients and optimize glycemic control in the hospital setting. they stabilize and treat dka and hhs. the inpatient setting provides an opportunity to institute therapies to slow disease progression, prevent disease complications, and provide diabetic education to improve quality of life and limit complications leading to readmission. hospitalists use evidence based approaches to optimize care and lead multidisciplinary teams to develop institutional guidelines or care pathways to optimize glycemic control.
KNOWLEDGE
Hospitalists should be able to:
Define diabetes mellitus and explain the pathophysiologic processes that can lead to hyperglycemia, dka and hhs.
Describe the impact of hyperglycemia on immune function and wound healing.
Describe the effect of dka and hhs on intravascular volume status, electrolytes and acid‐base balance.
Describe the clinical presentation and laboratory findings of dka and hhs.
Describe the indicated tests to evaluate and diagnose dka and hhs.
Explain physiologic stressors and medications that adversely impact glycemic control.
Explain the precipitating factors of dka and hss.
Identify the goals of glycemic control in hospitalized patients in various settings, including critically ill and surgical patients, and cite supporting evidence.
Explain indications, contraindications and mechanisms of action of pharmacologic agents used to treat diabetes mellitus.
Explain the rationale of strict glycemic control and its effects on morbidity and mortality in hospitalized patients.
Recognize factors that indicate severity of disease in patients with dka or hhs.
Explain goals for hospital discharge, including specific measures of clinical stability for safe care transition.
SKILLS
Hospitalists should be able to:
Elicit a thorough and relevant history, and review the medical record to identify symptoms suggestive of acute co‐morbid illness that can impact glycemic control.
Estimate the level of outpatient glycemic control, adherence to medication regimen, and social influences that may impact glycemic control.
Perform a comprehensive physical examination to identify possible precipitants of hyperglycemia, dka or hhs.
Identify precipitating factors for dka and hhs, including infection, myocardial ischemia, and adherence to medication regimen.
Select and interpret indicated studies in patients suspected of having dka or hhs, including electrolytes, beta‐hydroxybuterate, urinalysis, venous ph, and electrocardiogram.
Recognize the indications for managing dka and hhs in an intensive care unit.
Select appropriate insulin therapies, initiate fluid resuscitation, and manage the electrolyte disturbances caused by dka and hhs.
Adjust medications to achieve optimal glycemic control and minimize side effects.
Assess caloric and nutritional needs and order appropriate diabetic diet.
Recognize and address neuropathic pain.
Anticipate and manage the presence of ongoing metabolic derangements associated with dka and hhs.
Develop an individualized diabetic regimen to achieve optimal glycemic control and prevent the development of complications from diabetes mellitus, including during the perioperative period.
ATTITUDES
Hospitalists should be able to:
Communicate with patients and families to explain the history and prognosis of diabetes mellitus.
Communicate with patients and families to explain potential long‐term complications of diabetes mellitus and prevention strategies, including foot and eye care.
Communicate with patients and families to explain goals of care plan, discharge instructions and management after release from the hospital.
Communicate with patients and families to explain the importance of and factors affecting glycemic control, such as adherence to medical regimens and self‐monitoring, following dietary and exercise recommendations, and complying with routine follow‐up appointments.
Communicate with patients and families to explain the potential side effects or adverse interactions of diabetes medications, including hypoglycemia.
Recognize indications for early specialty consultation, which may include endocrinology and nutrition.
Employ a multidisciplinary approach, which may include nursing, nutrition and social services and a diabetes educator, to the care of patients with diabetes that begins at admission and continues through all care transitions.
Document treatment plan and discharge instructions, and communicate with the outpatient clinician responsible for follow‐up, including the need for continued nutrition and diabetic counseling.
Facilitate discharge planning early in the admission process.
Recommend appropriate post‐discharge care, which may include endocrinology, ophthalmology, and podiatry.
Utilize evidence based recommendation in the treatment of inpatients with diabetes mellitus.
SYSTEM ORGANIZATION AND IMPROVEMENT
To improve efficiency and quality within their organizations, hospitalists should:
Implement systems to ensure hospital‐wide adherence to national standards (american diabetes association and others), and document those measures as specified by recognized organizations.
Lead, coordinate or participate in efforts to develop guidelines and protocols that standardize assessment and aggressive treatment of dka and hhs.
Lead, coordinate or participate in efforts to develop guidelines and/or protocols to optimize glycemic control in hospitalized patients, including intensive regimens in critically ill medical and surgical patients.
Lead, coordinate or participate in multidisciplinary teams, which may include nursing, nutrition and endocrinology, to promote quality and cost‐effective diabetes management.
Diabetes mellitus is a disease characterized by abnormal insulin production or disordered glucose metabolism and is a co‐morbid condition of many hospitalized patients. diabetic ketoacidosis (dka) and hyperglycemia hyperosmolar state (hhs) are extreme presentations of diabetes mellitus that require hospitalization. there were 577,000 hospital discharges for diabetes mellitus in 2002, according to the american heart association. the prevalence of physician‐diagnosed diabetes mellitus was 13.9 million or 6.7 percent of the united states population. another 5.9 million americans are believed to have undiagnosed diabetes mellitus. the healthcare cost and utilization project (hcup) reports an average length‐of‐stay of 4.1 days and mean charges of $11,761 per patient for the diagnosis related group (drg) for diabetes mellitus. the estimated economic cost of diabetes in 2002 was $132 billion, of which $92 billion was direct medical costs. hospitalists care for diabetic patients and optimize glycemic control in the hospital setting. they stabilize and treat dka and hhs. the inpatient setting provides an opportunity to institute therapies to slow disease progression, prevent disease complications, and provide diabetic education to improve quality of life and limit complications leading to readmission. hospitalists use evidence based approaches to optimize care and lead multidisciplinary teams to develop institutional guidelines or care pathways to optimize glycemic control.
KNOWLEDGE
Hospitalists should be able to:
Define diabetes mellitus and explain the pathophysiologic processes that can lead to hyperglycemia, dka and hhs.
Describe the impact of hyperglycemia on immune function and wound healing.
Describe the effect of dka and hhs on intravascular volume status, electrolytes and acid‐base balance.
Describe the clinical presentation and laboratory findings of dka and hhs.
Describe the indicated tests to evaluate and diagnose dka and hhs.
Explain physiologic stressors and medications that adversely impact glycemic control.
Explain the precipitating factors of dka and hss.
Identify the goals of glycemic control in hospitalized patients in various settings, including critically ill and surgical patients, and cite supporting evidence.
Explain indications, contraindications and mechanisms of action of pharmacologic agents used to treat diabetes mellitus.
Explain the rationale of strict glycemic control and its effects on morbidity and mortality in hospitalized patients.
Recognize factors that indicate severity of disease in patients with dka or hhs.
Explain goals for hospital discharge, including specific measures of clinical stability for safe care transition.
SKILLS
Hospitalists should be able to:
Elicit a thorough and relevant history, and review the medical record to identify symptoms suggestive of acute co‐morbid illness that can impact glycemic control.
Estimate the level of outpatient glycemic control, adherence to medication regimen, and social influences that may impact glycemic control.
Perform a comprehensive physical examination to identify possible precipitants of hyperglycemia, dka or hhs.
Identify precipitating factors for dka and hhs, including infection, myocardial ischemia, and adherence to medication regimen.
Select and interpret indicated studies in patients suspected of having dka or hhs, including electrolytes, beta‐hydroxybuterate, urinalysis, venous ph, and electrocardiogram.
Recognize the indications for managing dka and hhs in an intensive care unit.
Select appropriate insulin therapies, initiate fluid resuscitation, and manage the electrolyte disturbances caused by dka and hhs.
Adjust medications to achieve optimal glycemic control and minimize side effects.
Assess caloric and nutritional needs and order appropriate diabetic diet.
Recognize and address neuropathic pain.
Anticipate and manage the presence of ongoing metabolic derangements associated with dka and hhs.
Develop an individualized diabetic regimen to achieve optimal glycemic control and prevent the development of complications from diabetes mellitus, including during the perioperative period.
ATTITUDES
Hospitalists should be able to:
Communicate with patients and families to explain the history and prognosis of diabetes mellitus.
Communicate with patients and families to explain potential long‐term complications of diabetes mellitus and prevention strategies, including foot and eye care.
Communicate with patients and families to explain goals of care plan, discharge instructions and management after release from the hospital.
Communicate with patients and families to explain the importance of and factors affecting glycemic control, such as adherence to medical regimens and self‐monitoring, following dietary and exercise recommendations, and complying with routine follow‐up appointments.
Communicate with patients and families to explain the potential side effects or adverse interactions of diabetes medications, including hypoglycemia.
Recognize indications for early specialty consultation, which may include endocrinology and nutrition.
Employ a multidisciplinary approach, which may include nursing, nutrition and social services and a diabetes educator, to the care of patients with diabetes that begins at admission and continues through all care transitions.
Document treatment plan and discharge instructions, and communicate with the outpatient clinician responsible for follow‐up, including the need for continued nutrition and diabetic counseling.
Facilitate discharge planning early in the admission process.
Recommend appropriate post‐discharge care, which may include endocrinology, ophthalmology, and podiatry.
Utilize evidence based recommendation in the treatment of inpatients with diabetes mellitus.
SYSTEM ORGANIZATION AND IMPROVEMENT
To improve efficiency and quality within their organizations, hospitalists should:
Implement systems to ensure hospital‐wide adherence to national standards (american diabetes association and others), and document those measures as specified by recognized organizations.
Lead, coordinate or participate in efforts to develop guidelines and protocols that standardize assessment and aggressive treatment of dka and hhs.
Lead, coordinate or participate in efforts to develop guidelines and/or protocols to optimize glycemic control in hospitalized patients, including intensive regimens in critically ill medical and surgical patients.
Lead, coordinate or participate in multidisciplinary teams, which may include nursing, nutrition and endocrinology, to promote quality and cost‐effective diabetes management.
Diabetes mellitus is a disease characterized by abnormal insulin production or disordered glucose metabolism and is a co‐morbid condition of many hospitalized patients. diabetic ketoacidosis (dka) and hyperglycemia hyperosmolar state (hhs) are extreme presentations of diabetes mellitus that require hospitalization. there were 577,000 hospital discharges for diabetes mellitus in 2002, according to the american heart association. the prevalence of physician‐diagnosed diabetes mellitus was 13.9 million or 6.7 percent of the united states population. another 5.9 million americans are believed to have undiagnosed diabetes mellitus. the healthcare cost and utilization project (hcup) reports an average length‐of‐stay of 4.1 days and mean charges of $11,761 per patient for the diagnosis related group (drg) for diabetes mellitus. the estimated economic cost of diabetes in 2002 was $132 billion, of which $92 billion was direct medical costs. hospitalists care for diabetic patients and optimize glycemic control in the hospital setting. they stabilize and treat dka and hhs. the inpatient setting provides an opportunity to institute therapies to slow disease progression, prevent disease complications, and provide diabetic education to improve quality of life and limit complications leading to readmission. hospitalists use evidence based approaches to optimize care and lead multidisciplinary teams to develop institutional guidelines or care pathways to optimize glycemic control.
KNOWLEDGE
Hospitalists should be able to:
Define diabetes mellitus and explain the pathophysiologic processes that can lead to hyperglycemia, dka and hhs.
Describe the impact of hyperglycemia on immune function and wound healing.
Describe the effect of dka and hhs on intravascular volume status, electrolytes and acid‐base balance.
Describe the clinical presentation and laboratory findings of dka and hhs.
Describe the indicated tests to evaluate and diagnose dka and hhs.
Explain physiologic stressors and medications that adversely impact glycemic control.
Explain the precipitating factors of dka and hss.
Identify the goals of glycemic control in hospitalized patients in various settings, including critically ill and surgical patients, and cite supporting evidence.
Explain indications, contraindications and mechanisms of action of pharmacologic agents used to treat diabetes mellitus.
Explain the rationale of strict glycemic control and its effects on morbidity and mortality in hospitalized patients.
Recognize factors that indicate severity of disease in patients with dka or hhs.
Explain goals for hospital discharge, including specific measures of clinical stability for safe care transition.
SKILLS
Hospitalists should be able to:
Elicit a thorough and relevant history, and review the medical record to identify symptoms suggestive of acute co‐morbid illness that can impact glycemic control.
Estimate the level of outpatient glycemic control, adherence to medication regimen, and social influences that may impact glycemic control.
Perform a comprehensive physical examination to identify possible precipitants of hyperglycemia, dka or hhs.
Identify precipitating factors for dka and hhs, including infection, myocardial ischemia, and adherence to medication regimen.
Select and interpret indicated studies in patients suspected of having dka or hhs, including electrolytes, beta‐hydroxybuterate, urinalysis, venous ph, and electrocardiogram.
Recognize the indications for managing dka and hhs in an intensive care unit.
Select appropriate insulin therapies, initiate fluid resuscitation, and manage the electrolyte disturbances caused by dka and hhs.
Adjust medications to achieve optimal glycemic control and minimize side effects.
Assess caloric and nutritional needs and order appropriate diabetic diet.
Recognize and address neuropathic pain.
Anticipate and manage the presence of ongoing metabolic derangements associated with dka and hhs.
Develop an individualized diabetic regimen to achieve optimal glycemic control and prevent the development of complications from diabetes mellitus, including during the perioperative period.
ATTITUDES
Hospitalists should be able to:
Communicate with patients and families to explain the history and prognosis of diabetes mellitus.
Communicate with patients and families to explain potential long‐term complications of diabetes mellitus and prevention strategies, including foot and eye care.
Communicate with patients and families to explain goals of care plan, discharge instructions and management after release from the hospital.
Communicate with patients and families to explain the importance of and factors affecting glycemic control, such as adherence to medical regimens and self‐monitoring, following dietary and exercise recommendations, and complying with routine follow‐up appointments.
Communicate with patients and families to explain the potential side effects or adverse interactions of diabetes medications, including hypoglycemia.
Recognize indications for early specialty consultation, which may include endocrinology and nutrition.
Employ a multidisciplinary approach, which may include nursing, nutrition and social services and a diabetes educator, to the care of patients with diabetes that begins at admission and continues through all care transitions.
Document treatment plan and discharge instructions, and communicate with the outpatient clinician responsible for follow‐up, including the need for continued nutrition and diabetic counseling.
Facilitate discharge planning early in the admission process.
Recommend appropriate post‐discharge care, which may include endocrinology, ophthalmology, and podiatry.
Utilize evidence based recommendation in the treatment of inpatients with diabetes mellitus.
SYSTEM ORGANIZATION AND IMPROVEMENT
To improve efficiency and quality within their organizations, hospitalists should:
Implement systems to ensure hospital‐wide adherence to national standards (american diabetes association and others), and document those measures as specified by recognized organizations.
Lead, coordinate or participate in efforts to develop guidelines and protocols that standardize assessment and aggressive treatment of dka and hhs.
Lead, coordinate or participate in efforts to develop guidelines and/or protocols to optimize glycemic control in hospitalized patients, including intensive regimens in critically ill medical and surgical patients.
Lead, coordinate or participate in multidisciplinary teams, which may include nursing, nutrition and endocrinology, to promote quality and cost‐effective diabetes management.
Copyright © 2006 Society of Hospital Medicine
Patient handoff
Patient handoff (or sign‐out) refers to the specific interaction, communication, and planning required to achieve seamless transitions of care from one clinician to another. Effective and timely sign‐outs are essential to maintain high quality medical care, reduce medical errors and redundancy, and prevent loss of information. Hospitalists are involved in the transfer of patient care on a daily basis and can lead institutional initiatives that promote optimal transfer of information between health care providers.
KNOWLEDGE
Hospitalists should be able to:
Describe key elements involved in signing out a patient.
Explain important information that should be communicated during patient sign‐out, which may include administrative details, updated clinical status, tasks to be completed and relative priority, severity of illness assessment, code status, and contingency planning.
Explain the components and strategies that are critical for successful communication during sign‐outs.
Explain how the components, strategies and specific information provided at sign‐out might vary depending on complexity of the patient, familiarity of provider with the patient and the care environment, and timing of sign‐out.
Explain the strengths and limitations of various sign‐out communication strategies and procedures.
SKILLS
Hospitalists should be able to:
Communicate effectively and efficiently during patient sign‐out.
Demonstrate the use of read back when communicating tasks.
Utilize the most efficient and effective verbal and written communication modalities.
Construct patient summaries for oral and written delivery, incorporating the unique characteristics of the patient, provider and timing of the sign‐out.
Evaluate all medications for indication, dosing, and planned duration at the time of sign‐out.
Document updated clinical status, recent and pending test and study results, a complete problem list, and plans for continued care.
Explain the importance of using if‐then statements for critical tasks to be completed.
Anticipate what may go wrong with a patient after a transition in care and communicate this clearly to the receiving clinician.
Synthesize medical information received from Hospitalists signing out patients into care plans
ATTITUDES
Hospitalists should be able to:
Inform patients and families in advance of sign‐out.
Recognize the impact of effective and ineffective sign‐outs on patient safety.
Appreciate the value of real time interactive dialogue between hospitalists during sign‐out.
Review received sign‐out summaries and communications information carefully and request clarification when needed.
Engage stakeholders in hospital initiatives to continuously assess the quality of sign‐outs.
Lead, coordinate or participate in initiatives to develop and implement new protocols to improve and optimize sign‐outs.
Lead, coordinate or participate in evaluation of new strategies or information systems designed to improve sign‐outs.
Promote availability after sign‐outs should questions arise.
Patient handoff (or sign‐out) refers to the specific interaction, communication, and planning required to achieve seamless transitions of care from one clinician to another. Effective and timely sign‐outs are essential to maintain high quality medical care, reduce medical errors and redundancy, and prevent loss of information. Hospitalists are involved in the transfer of patient care on a daily basis and can lead institutional initiatives that promote optimal transfer of information between health care providers.
KNOWLEDGE
Hospitalists should be able to:
Describe key elements involved in signing out a patient.
Explain important information that should be communicated during patient sign‐out, which may include administrative details, updated clinical status, tasks to be completed and relative priority, severity of illness assessment, code status, and contingency planning.
Explain the components and strategies that are critical for successful communication during sign‐outs.
Explain how the components, strategies and specific information provided at sign‐out might vary depending on complexity of the patient, familiarity of provider with the patient and the care environment, and timing of sign‐out.
Explain the strengths and limitations of various sign‐out communication strategies and procedures.
SKILLS
Hospitalists should be able to:
Communicate effectively and efficiently during patient sign‐out.
Demonstrate the use of read back when communicating tasks.
Utilize the most efficient and effective verbal and written communication modalities.
Construct patient summaries for oral and written delivery, incorporating the unique characteristics of the patient, provider and timing of the sign‐out.
Evaluate all medications for indication, dosing, and planned duration at the time of sign‐out.
Document updated clinical status, recent and pending test and study results, a complete problem list, and plans for continued care.
Explain the importance of using if‐then statements for critical tasks to be completed.
Anticipate what may go wrong with a patient after a transition in care and communicate this clearly to the receiving clinician.
Synthesize medical information received from Hospitalists signing out patients into care plans
ATTITUDES
Hospitalists should be able to:
Inform patients and families in advance of sign‐out.
Recognize the impact of effective and ineffective sign‐outs on patient safety.
Appreciate the value of real time interactive dialogue between hospitalists during sign‐out.
Review received sign‐out summaries and communications information carefully and request clarification when needed.
Engage stakeholders in hospital initiatives to continuously assess the quality of sign‐outs.
Lead, coordinate or participate in initiatives to develop and implement new protocols to improve and optimize sign‐outs.
Lead, coordinate or participate in evaluation of new strategies or information systems designed to improve sign‐outs.
Promote availability after sign‐outs should questions arise.
Patient handoff (or sign‐out) refers to the specific interaction, communication, and planning required to achieve seamless transitions of care from one clinician to another. Effective and timely sign‐outs are essential to maintain high quality medical care, reduce medical errors and redundancy, and prevent loss of information. Hospitalists are involved in the transfer of patient care on a daily basis and can lead institutional initiatives that promote optimal transfer of information between health care providers.
KNOWLEDGE
Hospitalists should be able to:
Describe key elements involved in signing out a patient.
Explain important information that should be communicated during patient sign‐out, which may include administrative details, updated clinical status, tasks to be completed and relative priority, severity of illness assessment, code status, and contingency planning.
Explain the components and strategies that are critical for successful communication during sign‐outs.
Explain how the components, strategies and specific information provided at sign‐out might vary depending on complexity of the patient, familiarity of provider with the patient and the care environment, and timing of sign‐out.
Explain the strengths and limitations of various sign‐out communication strategies and procedures.
SKILLS
Hospitalists should be able to:
Communicate effectively and efficiently during patient sign‐out.
Demonstrate the use of read back when communicating tasks.
Utilize the most efficient and effective verbal and written communication modalities.
Construct patient summaries for oral and written delivery, incorporating the unique characteristics of the patient, provider and timing of the sign‐out.
Evaluate all medications for indication, dosing, and planned duration at the time of sign‐out.
Document updated clinical status, recent and pending test and study results, a complete problem list, and plans for continued care.
Explain the importance of using if‐then statements for critical tasks to be completed.
Anticipate what may go wrong with a patient after a transition in care and communicate this clearly to the receiving clinician.
Synthesize medical information received from Hospitalists signing out patients into care plans
ATTITUDES
Hospitalists should be able to:
Inform patients and families in advance of sign‐out.
Recognize the impact of effective and ineffective sign‐outs on patient safety.
Appreciate the value of real time interactive dialogue between hospitalists during sign‐out.
Review received sign‐out summaries and communications information carefully and request clarification when needed.
Engage stakeholders in hospital initiatives to continuously assess the quality of sign‐outs.
Lead, coordinate or participate in initiatives to develop and implement new protocols to improve and optimize sign‐outs.
Lead, coordinate or participate in evaluation of new strategies or information systems designed to improve sign‐outs.
Promote availability after sign‐outs should questions arise.
Copyright © 2006 Society of Hospital Medicine
Congestive heart failure syndrome
Congestive heart failure syndrome (chf) is characterized by impaired function of the heart resulting in a constellation of symptoms and signs, which may include fatigue, weakness and shortness of breath. the american heart association (aha) reports that chf affects nearly 5 million people in the united states. chf accounted for 970,000 hospital discharges in 2002. medicare paid $3.6 billion for the care of patients with chf in 1999, or $5,456 per discharge. the estimated direct and indirect cost of chf in 2005 is $27.9 billion. despite published guidelines for chf management, there is significant variation in treatment for hospitalized patients. this variability significantly impacts individual patients, families and hospital systems, and accounts for billions of dollars of the medicare budget. hospitalists can lead their institutions in early diagnosis, initiation of evidence based medical therapy, and incorporation of a multidisciplinary approach to heart failure. hospitalists can also develop strategies to operationalize cost‐effective interventions that reduce morbidity, mortality and readmission rates.
KNOWLEDGE
Hospitalists should be able to:
Explain underlying causes of chf and precipitating factors leading to exacerbation.
Differentiate features of systolic and diastolic dysfunction, and explain the common etiologies of each.
Describe the indicated tests required to evaluate chf, including assessment of left ventricular function.
Describe risk factors for the development of chf in the hospital setting.
Risk stratify patients admitted with chf and determine the appropriate level of care.
Describe goals of inpatient therapy for acute decompensated heart failure including pre‐load and after‐load reduction, hemodynamic stabilization, and optimization of volume status.
Describe the role of invasive and noninvasive ventilatory support.
Explain evidence based therapeutic options for management of acute and chronic chf and describe contraindications to these therapies.
Explain indications, contraindications and mechanisms of action of pharmacologic agents used to treat chf.
Identify medications and interventions contraindicated in chf.
Explain markers of severity of the disease and factors that influence prognosis.
Explain goals for hospital discharge, including specific measures of clinical stability for safe care transition.
SKILLS
Hospitalists should be able to:
Elicit a thorough and relevant history and review the medical record to identify symptoms, co‐morbidities, medications, and/or social influences contributing to chf or its exacerbation.
Review inpatient records to determine iatrogenic influences of chf.
Recognize the clinical presentation of heart failure, including features of exacerbation and reliability of signs and symptoms.
Identify physical findings consistent with chf.
Identify signs of low perfusion states and cardiogenic shock.
Order indicated diagnostic testing to identify precipitating factors of chf and assess cardiac function.
Formulate an evidence based treatment plan, tailored to the individual patient, which may include pharmacologic agents and dosing, nutritional recommendations, and patient compliance.
Recognize symptoms and signs of acute decompensation and initiate immediate indicated therapies.
Assess patients with suspected heart failure in a timely manner, identify the level of care required, and manage or co‐manage the patient with the primary requesting service.
ATTITUDES
Hospitalists should be able to:
Communicate with patients and families to explain the history and prognosis of chf.
Communicate with patients and families to explain the importance of home self‐monitoring and adherence to medication regimens, nutritional recommendations, and physical rehabilitation.
Communicate with patients and families to explain goals of care plan, discharge instructions and management after release from hospital.
Communicate with patients and families to explain tests and procedures, and the use and potential side effects of pharmacologic agents.
Recognize indications for early cardiology consultation.
Recognize indications and qualifications for cardiac transplant evaluation.
Advocate the importance of behavioral modification to delay the progression of disease and improve quality of life.
Employ a multidisciplinary approach to the care of patients with chf that begins at admission and continues through all care transitions.
Recognize the importance of palliative care in the treatment of patients with chronic chf.
Responsibly address and respect end of life care wishes for patients with end‐stage chf.
Communicate to outpatient providers the relevant events of the hospitalization and post‐discharge needs, including pending tests, and determine who is responsible for checking the results.
Document treatment plan and provide clear discharge instructions for receiving primary care physician.
Utilize evidence based recommendations to guide diagnosis, monitoring and treatment of chf.
SYSTEM ORGANIZATION AND IMPROVEMENT
To improve efficiency and quality within their organizations, hospitalists should:
Advocate to hospital administrators to establish and support outpatient chf teams, which have been shown to reduce readmission rates and possibly morbidity and mortality through outreach to chf patients.
Lead, coordinate or participate in multidisciplinary teams, which may include nursing and social services, nutrition, pharmacy, and physical therapy, early in the hospital course to facilitate patient education and discharge planning; improve patient function and outcomes; and advocate patient outreach post‐discharge.
Implement systems to ensure hospital wide adherence to national standards and document those measures as specified by recognized organizations (jcaho, aha, acc, ahrq or others).
Lead, coordinate or participate in multidisciplinary initiatives to promote patient safety and optimize resource utilization.
Lead efforts to educate staff on the importance of smoking cessation counseling and other prevention measures.
Integrate outcomes research, institution‐specific laboratory policies, and hospital formulary to create indicated and cost‐effective diagnostic and management strategies for patients with chf.
Congestive heart failure syndrome (chf) is characterized by impaired function of the heart resulting in a constellation of symptoms and signs, which may include fatigue, weakness and shortness of breath. the american heart association (aha) reports that chf affects nearly 5 million people in the united states. chf accounted for 970,000 hospital discharges in 2002. medicare paid $3.6 billion for the care of patients with chf in 1999, or $5,456 per discharge. the estimated direct and indirect cost of chf in 2005 is $27.9 billion. despite published guidelines for chf management, there is significant variation in treatment for hospitalized patients. this variability significantly impacts individual patients, families and hospital systems, and accounts for billions of dollars of the medicare budget. hospitalists can lead their institutions in early diagnosis, initiation of evidence based medical therapy, and incorporation of a multidisciplinary approach to heart failure. hospitalists can also develop strategies to operationalize cost‐effective interventions that reduce morbidity, mortality and readmission rates.
KNOWLEDGE
Hospitalists should be able to:
Explain underlying causes of chf and precipitating factors leading to exacerbation.
Differentiate features of systolic and diastolic dysfunction, and explain the common etiologies of each.
Describe the indicated tests required to evaluate chf, including assessment of left ventricular function.
Describe risk factors for the development of chf in the hospital setting.
Risk stratify patients admitted with chf and determine the appropriate level of care.
Describe goals of inpatient therapy for acute decompensated heart failure including pre‐load and after‐load reduction, hemodynamic stabilization, and optimization of volume status.
Describe the role of invasive and noninvasive ventilatory support.
Explain evidence based therapeutic options for management of acute and chronic chf and describe contraindications to these therapies.
Explain indications, contraindications and mechanisms of action of pharmacologic agents used to treat chf.
Identify medications and interventions contraindicated in chf.
Explain markers of severity of the disease and factors that influence prognosis.
Explain goals for hospital discharge, including specific measures of clinical stability for safe care transition.
SKILLS
Hospitalists should be able to:
Elicit a thorough and relevant history and review the medical record to identify symptoms, co‐morbidities, medications, and/or social influences contributing to chf or its exacerbation.
Review inpatient records to determine iatrogenic influences of chf.
Recognize the clinical presentation of heart failure, including features of exacerbation and reliability of signs and symptoms.
Identify physical findings consistent with chf.
Identify signs of low perfusion states and cardiogenic shock.
Order indicated diagnostic testing to identify precipitating factors of chf and assess cardiac function.
Formulate an evidence based treatment plan, tailored to the individual patient, which may include pharmacologic agents and dosing, nutritional recommendations, and patient compliance.
Recognize symptoms and signs of acute decompensation and initiate immediate indicated therapies.
Assess patients with suspected heart failure in a timely manner, identify the level of care required, and manage or co‐manage the patient with the primary requesting service.
ATTITUDES
Hospitalists should be able to:
Communicate with patients and families to explain the history and prognosis of chf.
Communicate with patients and families to explain the importance of home self‐monitoring and adherence to medication regimens, nutritional recommendations, and physical rehabilitation.
Communicate with patients and families to explain goals of care plan, discharge instructions and management after release from hospital.
Communicate with patients and families to explain tests and procedures, and the use and potential side effects of pharmacologic agents.
Recognize indications for early cardiology consultation.
Recognize indications and qualifications for cardiac transplant evaluation.
Advocate the importance of behavioral modification to delay the progression of disease and improve quality of life.
Employ a multidisciplinary approach to the care of patients with chf that begins at admission and continues through all care transitions.
Recognize the importance of palliative care in the treatment of patients with chronic chf.
Responsibly address and respect end of life care wishes for patients with end‐stage chf.
Communicate to outpatient providers the relevant events of the hospitalization and post‐discharge needs, including pending tests, and determine who is responsible for checking the results.
Document treatment plan and provide clear discharge instructions for receiving primary care physician.
Utilize evidence based recommendations to guide diagnosis, monitoring and treatment of chf.
SYSTEM ORGANIZATION AND IMPROVEMENT
To improve efficiency and quality within their organizations, hospitalists should:
Advocate to hospital administrators to establish and support outpatient chf teams, which have been shown to reduce readmission rates and possibly morbidity and mortality through outreach to chf patients.
Lead, coordinate or participate in multidisciplinary teams, which may include nursing and social services, nutrition, pharmacy, and physical therapy, early in the hospital course to facilitate patient education and discharge planning; improve patient function and outcomes; and advocate patient outreach post‐discharge.
Implement systems to ensure hospital wide adherence to national standards and document those measures as specified by recognized organizations (jcaho, aha, acc, ahrq or others).
Lead, coordinate or participate in multidisciplinary initiatives to promote patient safety and optimize resource utilization.
Lead efforts to educate staff on the importance of smoking cessation counseling and other prevention measures.
Integrate outcomes research, institution‐specific laboratory policies, and hospital formulary to create indicated and cost‐effective diagnostic and management strategies for patients with chf.
Congestive heart failure syndrome (chf) is characterized by impaired function of the heart resulting in a constellation of symptoms and signs, which may include fatigue, weakness and shortness of breath. the american heart association (aha) reports that chf affects nearly 5 million people in the united states. chf accounted for 970,000 hospital discharges in 2002. medicare paid $3.6 billion for the care of patients with chf in 1999, or $5,456 per discharge. the estimated direct and indirect cost of chf in 2005 is $27.9 billion. despite published guidelines for chf management, there is significant variation in treatment for hospitalized patients. this variability significantly impacts individual patients, families and hospital systems, and accounts for billions of dollars of the medicare budget. hospitalists can lead their institutions in early diagnosis, initiation of evidence based medical therapy, and incorporation of a multidisciplinary approach to heart failure. hospitalists can also develop strategies to operationalize cost‐effective interventions that reduce morbidity, mortality and readmission rates.
KNOWLEDGE
Hospitalists should be able to:
Explain underlying causes of chf and precipitating factors leading to exacerbation.
Differentiate features of systolic and diastolic dysfunction, and explain the common etiologies of each.
Describe the indicated tests required to evaluate chf, including assessment of left ventricular function.
Describe risk factors for the development of chf in the hospital setting.
Risk stratify patients admitted with chf and determine the appropriate level of care.
Describe goals of inpatient therapy for acute decompensated heart failure including pre‐load and after‐load reduction, hemodynamic stabilization, and optimization of volume status.
Describe the role of invasive and noninvasive ventilatory support.
Explain evidence based therapeutic options for management of acute and chronic chf and describe contraindications to these therapies.
Explain indications, contraindications and mechanisms of action of pharmacologic agents used to treat chf.
Identify medications and interventions contraindicated in chf.
Explain markers of severity of the disease and factors that influence prognosis.
Explain goals for hospital discharge, including specific measures of clinical stability for safe care transition.
SKILLS
Hospitalists should be able to:
Elicit a thorough and relevant history and review the medical record to identify symptoms, co‐morbidities, medications, and/or social influences contributing to chf or its exacerbation.
Review inpatient records to determine iatrogenic influences of chf.
Recognize the clinical presentation of heart failure, including features of exacerbation and reliability of signs and symptoms.
Identify physical findings consistent with chf.
Identify signs of low perfusion states and cardiogenic shock.
Order indicated diagnostic testing to identify precipitating factors of chf and assess cardiac function.
Formulate an evidence based treatment plan, tailored to the individual patient, which may include pharmacologic agents and dosing, nutritional recommendations, and patient compliance.
Recognize symptoms and signs of acute decompensation and initiate immediate indicated therapies.
Assess patients with suspected heart failure in a timely manner, identify the level of care required, and manage or co‐manage the patient with the primary requesting service.
ATTITUDES
Hospitalists should be able to:
Communicate with patients and families to explain the history and prognosis of chf.
Communicate with patients and families to explain the importance of home self‐monitoring and adherence to medication regimens, nutritional recommendations, and physical rehabilitation.
Communicate with patients and families to explain goals of care plan, discharge instructions and management after release from hospital.
Communicate with patients and families to explain tests and procedures, and the use and potential side effects of pharmacologic agents.
Recognize indications for early cardiology consultation.
Recognize indications and qualifications for cardiac transplant evaluation.
Advocate the importance of behavioral modification to delay the progression of disease and improve quality of life.
Employ a multidisciplinary approach to the care of patients with chf that begins at admission and continues through all care transitions.
Recognize the importance of palliative care in the treatment of patients with chronic chf.
Responsibly address and respect end of life care wishes for patients with end‐stage chf.
Communicate to outpatient providers the relevant events of the hospitalization and post‐discharge needs, including pending tests, and determine who is responsible for checking the results.
Document treatment plan and provide clear discharge instructions for receiving primary care physician.
Utilize evidence based recommendations to guide diagnosis, monitoring and treatment of chf.
SYSTEM ORGANIZATION AND IMPROVEMENT
To improve efficiency and quality within their organizations, hospitalists should:
Advocate to hospital administrators to establish and support outpatient chf teams, which have been shown to reduce readmission rates and possibly morbidity and mortality through outreach to chf patients.
Lead, coordinate or participate in multidisciplinary teams, which may include nursing and social services, nutrition, pharmacy, and physical therapy, early in the hospital course to facilitate patient education and discharge planning; improve patient function and outcomes; and advocate patient outreach post‐discharge.
Implement systems to ensure hospital wide adherence to national standards and document those measures as specified by recognized organizations (jcaho, aha, acc, ahrq or others).
Lead, coordinate or participate in multidisciplinary initiatives to promote patient safety and optimize resource utilization.
Lead efforts to educate staff on the importance of smoking cessation counseling and other prevention measures.
Integrate outcomes research, institution‐specific laboratory policies, and hospital formulary to create indicated and cost‐effective diagnostic and management strategies for patients with chf.
Copyright © 2006 Society of Hospital Medicine
Thoracentesis
Thoracentesis is a bedside procedure involving the withdrawal of fluid from the pleural cavity. Pleural effusions are associated with several disease processes in hospitalized patients and may be evaluated using thoracentesis. The Healthcare Cost and Utilization Project (HCUP) estimates almost 189,000 thoracenteses were performed in hospitalized patients in 2002, although this total includes chest tube placement as well. Using the history, physical examination and radiographic findings, hospitalists identify those patients who would benefit from diagnostic or therapeutic thoracentesis.
KNOWLEDGE
Hospitalists should be able to:
Describe the normal anatomy of the chest wall, thorax and lung.
Define and differentiate the disease processes that may lead to the development of pleural effusion.
Define and differentiate transudative and exudative pleural effusions and their causes.
Explain indications and contraindications of thoracentesis and its potential risks and complications.
Explain the role of chest imaging in the evaluation of pleural effusion.
Explain the appropriate diagnostic testing for pleural fluid.
Describe indications for use of ultrasonography or computed tomography to assess the quantity of pleural fluid and/or guide thoracentesis.
Select the necessary equipment to perform a thoracentesis at the bedside, and differentiate what is needed for diagnostic versus therapeutic thoracentesis.
Define the criteria that distinguish transudative and exudative effusions.
Describe the effects of various disease processes on pleural fluid results.
SKILLS
Hospitalists should be able to:
Elicit a thorough history, identifying potential disease processes and risk factors for the development of pleural effusions.
Perform a chest examination, including specific maneuvers to assess for the presence of pleural effusion.
Properly position the patient and identify anatomic landmarks to perform a thoracentesis.
Use sterile techniques during preparation for and performance of thoracentesis.
Maintain clinician safety with appropriate protective wear.
Recognize and manage complications associated with thoracentesis, especially pneumothorax and re‐expansion pulmonary edema.
Order and interpret the results of pleural fluid analysis.
Order and interpret platelet and coagulation studies when indicated.
Determine need for chest tube placement based on thoracentesis results.
Synthesize a management plan based on history, physical examination, radiographic imaging and results of pleural fluid analysis.
Identify patients with pleural effusions who may benefit from therapeutic thoracentesis, chest tube placement and/or pleurodesis.
ATTITUDES
Hospitalists should be able to:
Communicate with patients and families to explain the procedure, its expected diagnostic or therapeutic benefits, and potential complications; and to obtain informed consent.
Order and promptly review the results of routine post‐procedure chest radiographs.
Manage patient discomfort or pain during and after the procedure.
Recognize indications for specialty consultations, which may include interventional radiology, pulmonary medicine, infectious disease, or cardiothoracic surgery.
SYSTEM ORGANIZATION AND IMPROVEMENT
To improve efficiency and quality within their organizations, Hospitalists should:
Lead, coordinate or participate in multidisciplinary initiatives to promote patient safety and optimize resource utilization.
Collaborate with radiologists to standardize identification of patients who would benefit from ultrasound‐guided thoracentesis.
Lead, coordinate or participate in efforts to develop strategies to minimize institution complication rates.
Lead, coordinate or participate in quality improvement programs to monitor hospitalists' performance and/or supervision of thoracentesis.
Lead, coordinate or participate in efforts to organize and consolidate thoracentesis equipment in an identifiable location in the hospital, easily accessible to clinicians who perform the procedure.
Thoracentesis is a bedside procedure involving the withdrawal of fluid from the pleural cavity. Pleural effusions are associated with several disease processes in hospitalized patients and may be evaluated using thoracentesis. The Healthcare Cost and Utilization Project (HCUP) estimates almost 189,000 thoracenteses were performed in hospitalized patients in 2002, although this total includes chest tube placement as well. Using the history, physical examination and radiographic findings, hospitalists identify those patients who would benefit from diagnostic or therapeutic thoracentesis.
KNOWLEDGE
Hospitalists should be able to:
Describe the normal anatomy of the chest wall, thorax and lung.
Define and differentiate the disease processes that may lead to the development of pleural effusion.
Define and differentiate transudative and exudative pleural effusions and their causes.
Explain indications and contraindications of thoracentesis and its potential risks and complications.
Explain the role of chest imaging in the evaluation of pleural effusion.
Explain the appropriate diagnostic testing for pleural fluid.
Describe indications for use of ultrasonography or computed tomography to assess the quantity of pleural fluid and/or guide thoracentesis.
Select the necessary equipment to perform a thoracentesis at the bedside, and differentiate what is needed for diagnostic versus therapeutic thoracentesis.
Define the criteria that distinguish transudative and exudative effusions.
Describe the effects of various disease processes on pleural fluid results.
SKILLS
Hospitalists should be able to:
Elicit a thorough history, identifying potential disease processes and risk factors for the development of pleural effusions.
Perform a chest examination, including specific maneuvers to assess for the presence of pleural effusion.
Properly position the patient and identify anatomic landmarks to perform a thoracentesis.
Use sterile techniques during preparation for and performance of thoracentesis.
Maintain clinician safety with appropriate protective wear.
Recognize and manage complications associated with thoracentesis, especially pneumothorax and re‐expansion pulmonary edema.
Order and interpret the results of pleural fluid analysis.
Order and interpret platelet and coagulation studies when indicated.
Determine need for chest tube placement based on thoracentesis results.
Synthesize a management plan based on history, physical examination, radiographic imaging and results of pleural fluid analysis.
Identify patients with pleural effusions who may benefit from therapeutic thoracentesis, chest tube placement and/or pleurodesis.
ATTITUDES
Hospitalists should be able to:
Communicate with patients and families to explain the procedure, its expected diagnostic or therapeutic benefits, and potential complications; and to obtain informed consent.
Order and promptly review the results of routine post‐procedure chest radiographs.
Manage patient discomfort or pain during and after the procedure.
Recognize indications for specialty consultations, which may include interventional radiology, pulmonary medicine, infectious disease, or cardiothoracic surgery.
SYSTEM ORGANIZATION AND IMPROVEMENT
To improve efficiency and quality within their organizations, Hospitalists should:
Lead, coordinate or participate in multidisciplinary initiatives to promote patient safety and optimize resource utilization.
Collaborate with radiologists to standardize identification of patients who would benefit from ultrasound‐guided thoracentesis.
Lead, coordinate or participate in efforts to develop strategies to minimize institution complication rates.
Lead, coordinate or participate in quality improvement programs to monitor hospitalists' performance and/or supervision of thoracentesis.
Lead, coordinate or participate in efforts to organize and consolidate thoracentesis equipment in an identifiable location in the hospital, easily accessible to clinicians who perform the procedure.
Thoracentesis is a bedside procedure involving the withdrawal of fluid from the pleural cavity. Pleural effusions are associated with several disease processes in hospitalized patients and may be evaluated using thoracentesis. The Healthcare Cost and Utilization Project (HCUP) estimates almost 189,000 thoracenteses were performed in hospitalized patients in 2002, although this total includes chest tube placement as well. Using the history, physical examination and radiographic findings, hospitalists identify those patients who would benefit from diagnostic or therapeutic thoracentesis.
KNOWLEDGE
Hospitalists should be able to:
Describe the normal anatomy of the chest wall, thorax and lung.
Define and differentiate the disease processes that may lead to the development of pleural effusion.
Define and differentiate transudative and exudative pleural effusions and their causes.
Explain indications and contraindications of thoracentesis and its potential risks and complications.
Explain the role of chest imaging in the evaluation of pleural effusion.
Explain the appropriate diagnostic testing for pleural fluid.
Describe indications for use of ultrasonography or computed tomography to assess the quantity of pleural fluid and/or guide thoracentesis.
Select the necessary equipment to perform a thoracentesis at the bedside, and differentiate what is needed for diagnostic versus therapeutic thoracentesis.
Define the criteria that distinguish transudative and exudative effusions.
Describe the effects of various disease processes on pleural fluid results.
SKILLS
Hospitalists should be able to:
Elicit a thorough history, identifying potential disease processes and risk factors for the development of pleural effusions.
Perform a chest examination, including specific maneuvers to assess for the presence of pleural effusion.
Properly position the patient and identify anatomic landmarks to perform a thoracentesis.
Use sterile techniques during preparation for and performance of thoracentesis.
Maintain clinician safety with appropriate protective wear.
Recognize and manage complications associated with thoracentesis, especially pneumothorax and re‐expansion pulmonary edema.
Order and interpret the results of pleural fluid analysis.
Order and interpret platelet and coagulation studies when indicated.
Determine need for chest tube placement based on thoracentesis results.
Synthesize a management plan based on history, physical examination, radiographic imaging and results of pleural fluid analysis.
Identify patients with pleural effusions who may benefit from therapeutic thoracentesis, chest tube placement and/or pleurodesis.
ATTITUDES
Hospitalists should be able to:
Communicate with patients and families to explain the procedure, its expected diagnostic or therapeutic benefits, and potential complications; and to obtain informed consent.
Order and promptly review the results of routine post‐procedure chest radiographs.
Manage patient discomfort or pain during and after the procedure.
Recognize indications for specialty consultations, which may include interventional radiology, pulmonary medicine, infectious disease, or cardiothoracic surgery.
SYSTEM ORGANIZATION AND IMPROVEMENT
To improve efficiency and quality within their organizations, Hospitalists should:
Lead, coordinate or participate in multidisciplinary initiatives to promote patient safety and optimize resource utilization.
Collaborate with radiologists to standardize identification of patients who would benefit from ultrasound‐guided thoracentesis.
Lead, coordinate or participate in efforts to develop strategies to minimize institution complication rates.
Lead, coordinate or participate in quality improvement programs to monitor hospitalists' performance and/or supervision of thoracentesis.
Lead, coordinate or participate in efforts to organize and consolidate thoracentesis equipment in an identifiable location in the hospital, easily accessible to clinicians who perform the procedure.
Copyright © 2006 Society of Hospital Medicine