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Delirium and dementia
Delirium is defined as a transient global disorder of cognition. many factors lead to delirium including baseline vulnerability interacting with precipitants during hospitalization. delirium affects an estimated 2.3 million hospitalized elders annually, accounting for 17.5 million inpatient days, and leading to more than $4 billion in medicare costs. it is associated with increased mortality, high rates of functional and cognitive decline, prolonged lengths of stay and high rates of skilled nursing facility placement. the cost of caring for patients with delirium significantly impacts individual patients, families and hospital systems, and accounts for billions of the medicare budget. hospitalists lead their institutions in the development of screening and prevention protocols for patients at risk for delirium, and in the promotion of safe approaches to treatment. hospitalists also develop strategies to operationalize cost‐effective delirium prevention programs that will improve outcomes.
Dementia is defined as a progressive decline in cognitive function, eventually limiting daily activities. dementia is a common co‐morbidity in the hospitalized elder. patients with dementia are at increased risk for delirium, falls, and functional decline during hospitalization. patients with baseline cognitive impairment have prolonged lengths of stay and complex needs after discharge. agitation and behavioral symptoms of dementia can exacerbate and be difficult to manage in the hospital setting. care of the patient with dementia requires that hospitalists engage in a multidisciplinary approach to inpatient and transitional care. hospitalists may also become involved in hospital quality and safety initiatives that pertain to areas such as restraint use and fall prevention.
KNOWLEDGE
Hospitalists should be able to:
Define delirium and dementia.
Distinguish the causes of delirium.
Describe the indicated tests required to evaluate delirium and dementia.
Recognize innate and environmental/ematrogenic risk factors for the development of delirium in the hospitalized patient.
Identify medications known to precipitate delirium.
Explain indications, contraindications and mechanisms of action of pharmacologic agents used to treat delirium and dementia.
Determine the best setting within the hospital to initiate, monitor, evaluate and treat patients with delirium.
Describe the poor outcomes related to delirium and dementia in the hospitalized patient.
Explain goals for hospital discharge, including specific measures of clinical stability for safe care transition.
SKILLS
Hospitalists should be able to:
Distinguish delirium and dementia from other causes of cognitive impairment, confusion or psychosis.
Predict a patient's risk for the development of delirium or poor outcomes related to dementia based on initial history and physical examination.
Screen for delirium using appropriate testing early and repeatedly during the patient's hospital course.
Perform a screen for dementia using the appropriate testing.
Apply known patient risk factors to create a care plan for reducing delirium.
Perform a focused evaluation for the underlying etiology of delirium and institute prompt treatment to lessen the severity of delirium.
Formulate and lead multidisciplinary teams to develop and implement care plans for patients with delirium or dementia.
Prescribe appropriate medications and dosing regimens for patients with delirium or dementia.
Repeatedly assess the need for additional interventions.
Assess patients with suspected delirium 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 delirium or dementia.
Communicate with patients and families to explain goals of care plan, discharge instructions and management after release from hospital.
Educate and engage families in the care of elder inpatients.
Establish goals and boundaries of care with patients and their family.
Communicate with the families and others with durable powers of attorney to explain tests and procedures and their indications, and to obtain informed consent.
Recognize the indications for specialty consultations.
Describe methods for the prevention of delirium.
Employ a multidisciplinary approach to the care of patients with delirium or dementia that begins at admission and continues through all care transitions.
Responsibly address and respect end of life care wishes for patients with advanced dementia.
Realize the multi‐faceted impact of delirium or dementia on patients and their families.
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 and family with contact information for follow‐up care, support and rehabilitation.
Utilize evidence based recommendations to guide diagnosis, monitoring and treatment of delirium and its causes.
SYSTEM ORGANIZATION AND IMPROVEMENT
To improve efficiency and quality within their organizations, hospitalists should:
Lead multidisciplinary teams to develop early treatment protocols.
Lead, coordinate or participate in multidisciplinary initiatives to implement screening and prevention protocols for patients at risk for delirium or poor outcomes related to dementia.
Engage stakeholders in hospital initiatives to improve safety and quality in the care of delirious and demented patients (e.g. provide diversion activities rather than using restraints).
Lead, coordinate or participate in multidisciplinary initiatives, which may include collaboration with geriatricians, to promote patient safety and cost‐effective diagnostic and management strategies for elderly patients.
Delirium is defined as a transient global disorder of cognition. many factors lead to delirium including baseline vulnerability interacting with precipitants during hospitalization. delirium affects an estimated 2.3 million hospitalized elders annually, accounting for 17.5 million inpatient days, and leading to more than $4 billion in medicare costs. it is associated with increased mortality, high rates of functional and cognitive decline, prolonged lengths of stay and high rates of skilled nursing facility placement. the cost of caring for patients with delirium significantly impacts individual patients, families and hospital systems, and accounts for billions of the medicare budget. hospitalists lead their institutions in the development of screening and prevention protocols for patients at risk for delirium, and in the promotion of safe approaches to treatment. hospitalists also develop strategies to operationalize cost‐effective delirium prevention programs that will improve outcomes.
Dementia is defined as a progressive decline in cognitive function, eventually limiting daily activities. dementia is a common co‐morbidity in the hospitalized elder. patients with dementia are at increased risk for delirium, falls, and functional decline during hospitalization. patients with baseline cognitive impairment have prolonged lengths of stay and complex needs after discharge. agitation and behavioral symptoms of dementia can exacerbate and be difficult to manage in the hospital setting. care of the patient with dementia requires that hospitalists engage in a multidisciplinary approach to inpatient and transitional care. hospitalists may also become involved in hospital quality and safety initiatives that pertain to areas such as restraint use and fall prevention.
KNOWLEDGE
Hospitalists should be able to:
Define delirium and dementia.
Distinguish the causes of delirium.
Describe the indicated tests required to evaluate delirium and dementia.
Recognize innate and environmental/ematrogenic risk factors for the development of delirium in the hospitalized patient.
Identify medications known to precipitate delirium.
Explain indications, contraindications and mechanisms of action of pharmacologic agents used to treat delirium and dementia.
Determine the best setting within the hospital to initiate, monitor, evaluate and treat patients with delirium.
Describe the poor outcomes related to delirium and dementia in the hospitalized patient.
Explain goals for hospital discharge, including specific measures of clinical stability for safe care transition.
SKILLS
Hospitalists should be able to:
Distinguish delirium and dementia from other causes of cognitive impairment, confusion or psychosis.
Predict a patient's risk for the development of delirium or poor outcomes related to dementia based on initial history and physical examination.
Screen for delirium using appropriate testing early and repeatedly during the patient's hospital course.
Perform a screen for dementia using the appropriate testing.
Apply known patient risk factors to create a care plan for reducing delirium.
Perform a focused evaluation for the underlying etiology of delirium and institute prompt treatment to lessen the severity of delirium.
Formulate and lead multidisciplinary teams to develop and implement care plans for patients with delirium or dementia.
Prescribe appropriate medications and dosing regimens for patients with delirium or dementia.
Repeatedly assess the need for additional interventions.
Assess patients with suspected delirium 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 delirium or dementia.
Communicate with patients and families to explain goals of care plan, discharge instructions and management after release from hospital.
Educate and engage families in the care of elder inpatients.
Establish goals and boundaries of care with patients and their family.
Communicate with the families and others with durable powers of attorney to explain tests and procedures and their indications, and to obtain informed consent.
Recognize the indications for specialty consultations.
Describe methods for the prevention of delirium.
Employ a multidisciplinary approach to the care of patients with delirium or dementia that begins at admission and continues through all care transitions.
Responsibly address and respect end of life care wishes for patients with advanced dementia.
Realize the multi‐faceted impact of delirium or dementia on patients and their families.
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 and family with contact information for follow‐up care, support and rehabilitation.
Utilize evidence based recommendations to guide diagnosis, monitoring and treatment of delirium and its causes.
SYSTEM ORGANIZATION AND IMPROVEMENT
To improve efficiency and quality within their organizations, hospitalists should:
Lead multidisciplinary teams to develop early treatment protocols.
Lead, coordinate or participate in multidisciplinary initiatives to implement screening and prevention protocols for patients at risk for delirium or poor outcomes related to dementia.
Engage stakeholders in hospital initiatives to improve safety and quality in the care of delirious and demented patients (e.g. provide diversion activities rather than using restraints).
Lead, coordinate or participate in multidisciplinary initiatives, which may include collaboration with geriatricians, to promote patient safety and cost‐effective diagnostic and management strategies for elderly patients.
Delirium is defined as a transient global disorder of cognition. many factors lead to delirium including baseline vulnerability interacting with precipitants during hospitalization. delirium affects an estimated 2.3 million hospitalized elders annually, accounting for 17.5 million inpatient days, and leading to more than $4 billion in medicare costs. it is associated with increased mortality, high rates of functional and cognitive decline, prolonged lengths of stay and high rates of skilled nursing facility placement. the cost of caring for patients with delirium significantly impacts individual patients, families and hospital systems, and accounts for billions of the medicare budget. hospitalists lead their institutions in the development of screening and prevention protocols for patients at risk for delirium, and in the promotion of safe approaches to treatment. hospitalists also develop strategies to operationalize cost‐effective delirium prevention programs that will improve outcomes.
Dementia is defined as a progressive decline in cognitive function, eventually limiting daily activities. dementia is a common co‐morbidity in the hospitalized elder. patients with dementia are at increased risk for delirium, falls, and functional decline during hospitalization. patients with baseline cognitive impairment have prolonged lengths of stay and complex needs after discharge. agitation and behavioral symptoms of dementia can exacerbate and be difficult to manage in the hospital setting. care of the patient with dementia requires that hospitalists engage in a multidisciplinary approach to inpatient and transitional care. hospitalists may also become involved in hospital quality and safety initiatives that pertain to areas such as restraint use and fall prevention.
KNOWLEDGE
Hospitalists should be able to:
Define delirium and dementia.
Distinguish the causes of delirium.
Describe the indicated tests required to evaluate delirium and dementia.
Recognize innate and environmental/ematrogenic risk factors for the development of delirium in the hospitalized patient.
Identify medications known to precipitate delirium.
Explain indications, contraindications and mechanisms of action of pharmacologic agents used to treat delirium and dementia.
Determine the best setting within the hospital to initiate, monitor, evaluate and treat patients with delirium.
Describe the poor outcomes related to delirium and dementia in the hospitalized patient.
Explain goals for hospital discharge, including specific measures of clinical stability for safe care transition.
SKILLS
Hospitalists should be able to:
Distinguish delirium and dementia from other causes of cognitive impairment, confusion or psychosis.
Predict a patient's risk for the development of delirium or poor outcomes related to dementia based on initial history and physical examination.
Screen for delirium using appropriate testing early and repeatedly during the patient's hospital course.
Perform a screen for dementia using the appropriate testing.
Apply known patient risk factors to create a care plan for reducing delirium.
Perform a focused evaluation for the underlying etiology of delirium and institute prompt treatment to lessen the severity of delirium.
Formulate and lead multidisciplinary teams to develop and implement care plans for patients with delirium or dementia.
Prescribe appropriate medications and dosing regimens for patients with delirium or dementia.
Repeatedly assess the need for additional interventions.
Assess patients with suspected delirium 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 delirium or dementia.
Communicate with patients and families to explain goals of care plan, discharge instructions and management after release from hospital.
Educate and engage families in the care of elder inpatients.
Establish goals and boundaries of care with patients and their family.
Communicate with the families and others with durable powers of attorney to explain tests and procedures and their indications, and to obtain informed consent.
Recognize the indications for specialty consultations.
Describe methods for the prevention of delirium.
Employ a multidisciplinary approach to the care of patients with delirium or dementia that begins at admission and continues through all care transitions.
Responsibly address and respect end of life care wishes for patients with advanced dementia.
Realize the multi‐faceted impact of delirium or dementia on patients and their families.
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 and family with contact information for follow‐up care, support and rehabilitation.
Utilize evidence based recommendations to guide diagnosis, monitoring and treatment of delirium and its causes.
SYSTEM ORGANIZATION AND IMPROVEMENT
To improve efficiency and quality within their organizations, hospitalists should:
Lead multidisciplinary teams to develop early treatment protocols.
Lead, coordinate or participate in multidisciplinary initiatives to implement screening and prevention protocols for patients at risk for delirium or poor outcomes related to dementia.
Engage stakeholders in hospital initiatives to improve safety and quality in the care of delirious and demented patients (e.g. provide diversion activities rather than using restraints).
Lead, coordinate or participate in multidisciplinary initiatives, which may include collaboration with geriatricians, to promote patient safety and cost‐effective diagnostic and management strategies for elderly patients.
Copyright © 2006 Society of Hospital Medicine
The core competencies in hospital medicine: A framework for curriculum development by the society of hospital medicine
| Acknowledgement | v |
| Editors and Contributors | vii |
| Introduction | xv |
| 1.1 | Acute Coronary Syndrome | 2 |
| 1.2 | Acute Renal Failure | 4 |
| 1.3 | Alcohol and Drug Withdrawal | 6 |
| 1.4 | Asthma | 8 |
| 1.5 | Cardiac Arrhythmia | 10 |
| 1.6 | Cellulitis | 12 |
| 1.7 | Chronic Obstructive Pulmonary Disease | 14 |
| 1.8 | Community‐Acquired Pneumonia | 16 |
| 1.9 | Congestive Heart Failure | 18 |
| 1.10 | Delirium and Dementia | 20 |
| 1.11 | Diabetes Mellitus | 22 |
| 1.12 | Gastrointestinal Bleed | 24 |
| 1.13 | Hospital‐Acquired Pneumonia | 26 |
| 1.14 | Pain Management | 28 |
| 1.15 | Perioperative Medicine | 30 |
| 1.16 | Sepsis Syndrome | 32 |
| 1.17 | Stroke | 34 |
| 1.18 | Urinary Tract Infection | 36 |
| 1.19 | Venous Thromboembolism | 38 |
| 2.1 | Arthrocentesis | 42 |
| 2.2 | Chest Radiograph Interpretation | 44 |
| 2.3 | Electrocardiogram Interpretation | 45 |
| 2.4 | Emergency Procedures | 46 |
| 2.5 | Lumbar Puncture | 50 |
| 2.6 | Paracentesis | 52 |
| 2.7 | Thoracentesis | 54 |
| 2.8 | Vascular Access | 56 |
| 3.1 | Care of the Elderly Patient | 60 |
| 3.2 | Care of Vulnerable Populations | 62 |
| 3.3 | Communication | 63 |
| 3.4 | Diagnostic Decision Making | 65 |
| 3.5 | Drug Safety, Pharmacoeconomics and Pharmacoepidemiology | 66 |
| 3.6 | Equitable Allocation of Resources | 68 |
| 3.7 | Evidence Based Medicine | 69 |
| 3.8 | Hospitalist as Consultant | 70 |
| 3.9 | Hospitalist as Teacher | 72 |
| 3.10 | Information Management | 75 |
| 3.11 | Leadership | 76 |
| 3.12 | Management Practices | 78 |
| 3.13 | Nutrition and the Hospitalized Patient | 79 |
| 3.14 | Palliative Care | 80 |
| 3.15 | Patient Education | 82 |
| 3.16 | Patient Handoff | 83 |
| 3.17 | Patient Safety | 84 |
| 3.18 | Practice Based Learning and Improvement | 87 |
| 3.19 | Prevention of Healthcare Associated Infections and Antimicrobial Resistance | 88 |
| 3.20 | Professionalism and Medical Ethics | 90 |
| 3.21 | Quality Improvement | 92 |
| 3.22 | Risk Management | 93 |
| 3.23 | Team Approach and Multidisciplinary Care | 94 |
| 3.24 | Transitions of Care | 95 |
APPENDICES
Abbreviations
Organizations Cited in Text
Core Competencies in Hospital Medicine: Development and Methodology Daniel D. Dressler, Michael J. Pistoria, Tina L. Budnitz, Sylvia C. W. McKean, and Alpesh N. Amin Reprinted from Journal of Hospital Medicine, Volume 1, Number 1, 2006, Pages 48‐56
How to Use The Core Competencies in Hospital Medicine: A Framework for Curriculum Development Sylvia C. W. McKean, Tina L. Budnitz, Daniel D. Dressler, Alpesh N. Amin, and Michael J. Pistoria Reprinted from Journal of Hospital Medicine, Volume 1, Number 1, 2006, Pages 57‐67
| Acknowledgement | v |
| Editors and Contributors | vii |
| Introduction | xv |
| 1.1 | Acute Coronary Syndrome | 2 |
| 1.2 | Acute Renal Failure | 4 |
| 1.3 | Alcohol and Drug Withdrawal | 6 |
| 1.4 | Asthma | 8 |
| 1.5 | Cardiac Arrhythmia | 10 |
| 1.6 | Cellulitis | 12 |
| 1.7 | Chronic Obstructive Pulmonary Disease | 14 |
| 1.8 | Community‐Acquired Pneumonia | 16 |
| 1.9 | Congestive Heart Failure | 18 |
| 1.10 | Delirium and Dementia | 20 |
| 1.11 | Diabetes Mellitus | 22 |
| 1.12 | Gastrointestinal Bleed | 24 |
| 1.13 | Hospital‐Acquired Pneumonia | 26 |
| 1.14 | Pain Management | 28 |
| 1.15 | Perioperative Medicine | 30 |
| 1.16 | Sepsis Syndrome | 32 |
| 1.17 | Stroke | 34 |
| 1.18 | Urinary Tract Infection | 36 |
| 1.19 | Venous Thromboembolism | 38 |
| 2.1 | Arthrocentesis | 42 |
| 2.2 | Chest Radiograph Interpretation | 44 |
| 2.3 | Electrocardiogram Interpretation | 45 |
| 2.4 | Emergency Procedures | 46 |
| 2.5 | Lumbar Puncture | 50 |
| 2.6 | Paracentesis | 52 |
| 2.7 | Thoracentesis | 54 |
| 2.8 | Vascular Access | 56 |
| 3.1 | Care of the Elderly Patient | 60 |
| 3.2 | Care of Vulnerable Populations | 62 |
| 3.3 | Communication | 63 |
| 3.4 | Diagnostic Decision Making | 65 |
| 3.5 | Drug Safety, Pharmacoeconomics and Pharmacoepidemiology | 66 |
| 3.6 | Equitable Allocation of Resources | 68 |
| 3.7 | Evidence Based Medicine | 69 |
| 3.8 | Hospitalist as Consultant | 70 |
| 3.9 | Hospitalist as Teacher | 72 |
| 3.10 | Information Management | 75 |
| 3.11 | Leadership | 76 |
| 3.12 | Management Practices | 78 |
| 3.13 | Nutrition and the Hospitalized Patient | 79 |
| 3.14 | Palliative Care | 80 |
| 3.15 | Patient Education | 82 |
| 3.16 | Patient Handoff | 83 |
| 3.17 | Patient Safety | 84 |
| 3.18 | Practice Based Learning and Improvement | 87 |
| 3.19 | Prevention of Healthcare Associated Infections and Antimicrobial Resistance | 88 |
| 3.20 | Professionalism and Medical Ethics | 90 |
| 3.21 | Quality Improvement | 92 |
| 3.22 | Risk Management | 93 |
| 3.23 | Team Approach and Multidisciplinary Care | 94 |
| 3.24 | Transitions of Care | 95 |
APPENDICES
Abbreviations
Organizations Cited in Text
Core Competencies in Hospital Medicine: Development and Methodology Daniel D. Dressler, Michael J. Pistoria, Tina L. Budnitz, Sylvia C. W. McKean, and Alpesh N. Amin Reprinted from Journal of Hospital Medicine, Volume 1, Number 1, 2006, Pages 48‐56
How to Use The Core Competencies in Hospital Medicine: A Framework for Curriculum Development Sylvia C. W. McKean, Tina L. Budnitz, Daniel D. Dressler, Alpesh N. Amin, and Michael J. Pistoria Reprinted from Journal of Hospital Medicine, Volume 1, Number 1, 2006, Pages 57‐67
| Acknowledgement | v |
| Editors and Contributors | vii |
| Introduction | xv |
| 1.1 | Acute Coronary Syndrome | 2 |
| 1.2 | Acute Renal Failure | 4 |
| 1.3 | Alcohol and Drug Withdrawal | 6 |
| 1.4 | Asthma | 8 |
| 1.5 | Cardiac Arrhythmia | 10 |
| 1.6 | Cellulitis | 12 |
| 1.7 | Chronic Obstructive Pulmonary Disease | 14 |
| 1.8 | Community‐Acquired Pneumonia | 16 |
| 1.9 | Congestive Heart Failure | 18 |
| 1.10 | Delirium and Dementia | 20 |
| 1.11 | Diabetes Mellitus | 22 |
| 1.12 | Gastrointestinal Bleed | 24 |
| 1.13 | Hospital‐Acquired Pneumonia | 26 |
| 1.14 | Pain Management | 28 |
| 1.15 | Perioperative Medicine | 30 |
| 1.16 | Sepsis Syndrome | 32 |
| 1.17 | Stroke | 34 |
| 1.18 | Urinary Tract Infection | 36 |
| 1.19 | Venous Thromboembolism | 38 |
| 2.1 | Arthrocentesis | 42 |
| 2.2 | Chest Radiograph Interpretation | 44 |
| 2.3 | Electrocardiogram Interpretation | 45 |
| 2.4 | Emergency Procedures | 46 |
| 2.5 | Lumbar Puncture | 50 |
| 2.6 | Paracentesis | 52 |
| 2.7 | Thoracentesis | 54 |
| 2.8 | Vascular Access | 56 |
| 3.1 | Care of the Elderly Patient | 60 |
| 3.2 | Care of Vulnerable Populations | 62 |
| 3.3 | Communication | 63 |
| 3.4 | Diagnostic Decision Making | 65 |
| 3.5 | Drug Safety, Pharmacoeconomics and Pharmacoepidemiology | 66 |
| 3.6 | Equitable Allocation of Resources | 68 |
| 3.7 | Evidence Based Medicine | 69 |
| 3.8 | Hospitalist as Consultant | 70 |
| 3.9 | Hospitalist as Teacher | 72 |
| 3.10 | Information Management | 75 |
| 3.11 | Leadership | 76 |
| 3.12 | Management Practices | 78 |
| 3.13 | Nutrition and the Hospitalized Patient | 79 |
| 3.14 | Palliative Care | 80 |
| 3.15 | Patient Education | 82 |
| 3.16 | Patient Handoff | 83 |
| 3.17 | Patient Safety | 84 |
| 3.18 | Practice Based Learning and Improvement | 87 |
| 3.19 | Prevention of Healthcare Associated Infections and Antimicrobial Resistance | 88 |
| 3.20 | Professionalism and Medical Ethics | 90 |
| 3.21 | Quality Improvement | 92 |
| 3.22 | Risk Management | 93 |
| 3.23 | Team Approach and Multidisciplinary Care | 94 |
| 3.24 | Transitions of Care | 95 |
APPENDICES
Abbreviations
Organizations Cited in Text
Core Competencies in Hospital Medicine: Development and Methodology Daniel D. Dressler, Michael J. Pistoria, Tina L. Budnitz, Sylvia C. W. McKean, and Alpesh N. Amin Reprinted from Journal of Hospital Medicine, Volume 1, Number 1, 2006, Pages 48‐56
How to Use The Core Competencies in Hospital Medicine: A Framework for Curriculum Development Sylvia C. W. McKean, Tina L. Budnitz, Daniel D. Dressler, Alpesh N. Amin, and Michael J. Pistoria Reprinted from Journal of Hospital Medicine, Volume 1, Number 1, 2006, Pages 57‐67
Copyright © 2006 Society of Hospital Medicine
Practice based learning and improvement
Practice Based Learning and Improvement (PBLI) is a means of evaluating individual and system practice patterns and incorporating the best available evidence to improve patient care. PBLI is recognized as a critical skill for all clinicians by the Accreditation Council for Graduate Medical Education (ACGME), the American Board of Internal Medicine (ABIM), and the American Board of Pediatrics (ABP). As the practice of Hospital Medicine rapidly evolves, hospitalists apply the most up‐to‐date knowledge to their care of inpatients. Hospitalists use a PBLI approach to lead, coordinate and participate in initiatives to improve hospital processes and clinical care.
KNOWLEDGE
Hospitalists should be able to:
Describe systematic methods of analyzing practice experience.
Explain key concepts of practice based improvement methodology, which include the Plan Do Study Act (PDSA) model.
Define the role of multidisciplinary teams and team leaders in improving patient care.
Describe how critical appraisal skills, including study design, statistical methods and clinical relevance apply to PBLI.
Describe how information technology can be used to identify opportunities to improve patient care.
SKILLS
Hospitalists should be able to:
Translate information about a general population into management of subpopulations or individual patients.
Critically assess individual and system practice patterns and experience to identify areas for improvement and minimize heterogeneity of practice.
Design practice interventions to improve quality, efficiency, and consistency of patient care using standard PBLI methodology and tools.
Assess medical information to support self‐directed learning.
Establish and maintain an open dialogue with patients and families regarding care goals and limitations, palliative care, and end of life issues.
Critically appraise and apply the reports of new medical evidence.
Use health information systems efficiently to manage and improve care at the individual and system levels.
Utilize evidence based information resources to inform clinical decisions.
ATTITUDES
Hospitalists should be able to:
Advocate for the use of PBLI in clinical practice and in system improvement projects.
Create an environment conducive to self‐evaluation and improvement.
Advocate for investment in information technology.
Facilitate and encourage self‐directed learning among health care professionals and trainees.
Promote self improvement and care standardization, utilizing best evidence and practice.
Practice Based Learning and Improvement (PBLI) is a means of evaluating individual and system practice patterns and incorporating the best available evidence to improve patient care. PBLI is recognized as a critical skill for all clinicians by the Accreditation Council for Graduate Medical Education (ACGME), the American Board of Internal Medicine (ABIM), and the American Board of Pediatrics (ABP). As the practice of Hospital Medicine rapidly evolves, hospitalists apply the most up‐to‐date knowledge to their care of inpatients. Hospitalists use a PBLI approach to lead, coordinate and participate in initiatives to improve hospital processes and clinical care.
KNOWLEDGE
Hospitalists should be able to:
Describe systematic methods of analyzing practice experience.
Explain key concepts of practice based improvement methodology, which include the Plan Do Study Act (PDSA) model.
Define the role of multidisciplinary teams and team leaders in improving patient care.
Describe how critical appraisal skills, including study design, statistical methods and clinical relevance apply to PBLI.
Describe how information technology can be used to identify opportunities to improve patient care.
SKILLS
Hospitalists should be able to:
Translate information about a general population into management of subpopulations or individual patients.
Critically assess individual and system practice patterns and experience to identify areas for improvement and minimize heterogeneity of practice.
Design practice interventions to improve quality, efficiency, and consistency of patient care using standard PBLI methodology and tools.
Assess medical information to support self‐directed learning.
Establish and maintain an open dialogue with patients and families regarding care goals and limitations, palliative care, and end of life issues.
Critically appraise and apply the reports of new medical evidence.
Use health information systems efficiently to manage and improve care at the individual and system levels.
Utilize evidence based information resources to inform clinical decisions.
ATTITUDES
Hospitalists should be able to:
Advocate for the use of PBLI in clinical practice and in system improvement projects.
Create an environment conducive to self‐evaluation and improvement.
Advocate for investment in information technology.
Facilitate and encourage self‐directed learning among health care professionals and trainees.
Promote self improvement and care standardization, utilizing best evidence and practice.
Practice Based Learning and Improvement (PBLI) is a means of evaluating individual and system practice patterns and incorporating the best available evidence to improve patient care. PBLI is recognized as a critical skill for all clinicians by the Accreditation Council for Graduate Medical Education (ACGME), the American Board of Internal Medicine (ABIM), and the American Board of Pediatrics (ABP). As the practice of Hospital Medicine rapidly evolves, hospitalists apply the most up‐to‐date knowledge to their care of inpatients. Hospitalists use a PBLI approach to lead, coordinate and participate in initiatives to improve hospital processes and clinical care.
KNOWLEDGE
Hospitalists should be able to:
Describe systematic methods of analyzing practice experience.
Explain key concepts of practice based improvement methodology, which include the Plan Do Study Act (PDSA) model.
Define the role of multidisciplinary teams and team leaders in improving patient care.
Describe how critical appraisal skills, including study design, statistical methods and clinical relevance apply to PBLI.
Describe how information technology can be used to identify opportunities to improve patient care.
SKILLS
Hospitalists should be able to:
Translate information about a general population into management of subpopulations or individual patients.
Critically assess individual and system practice patterns and experience to identify areas for improvement and minimize heterogeneity of practice.
Design practice interventions to improve quality, efficiency, and consistency of patient care using standard PBLI methodology and tools.
Assess medical information to support self‐directed learning.
Establish and maintain an open dialogue with patients and families regarding care goals and limitations, palliative care, and end of life issues.
Critically appraise and apply the reports of new medical evidence.
Use health information systems efficiently to manage and improve care at the individual and system levels.
Utilize evidence based information resources to inform clinical decisions.
ATTITUDES
Hospitalists should be able to:
Advocate for the use of PBLI in clinical practice and in system improvement projects.
Create an environment conducive to self‐evaluation and improvement.
Advocate for investment in information technology.
Facilitate and encourage self‐directed learning among health care professionals and trainees.
Promote self improvement and care standardization, utilizing best evidence and practice.
Copyright © 2006 Society of Hospital Medicine
Chronic obstructive pulmonary disease
Chronic obstructive pulmonary disease (copd) involves progressive pulmonary airflow limitation that is not completely reversible, and is associated with an abnormal airway inflammatory response. copd affects over 11 million americans and is the fourth most common cause of death in the united states and canada. copd exacerbation is defined as an increase in the usual symptoms of copd and can often result in hospitalization. the diagnosis related group (drg) for copd had 652,000 discharges in 2002, according to the healthcare cost and utilization project (hcup). mean charges for these patients were $13,000 per patient and the mean length‐of‐stay was 4.7 days with in‐hospital mortality of 1.7%. hospitalists use evidence based approaches to optimize care, and can lead multidisciplinary teams to develop institutional guidelines or care pathways to reduce readmission rates and mortality from copd exacerbation.
KNOWLEDGE
Hospitalists should be able to:
Define copd and describe the pathophysiologic processes that lead to small airway obstruction and alveolar destruction.
Describe potential precipitants of exacerbation, including infectious and non‐infectious etiologies.
Recognize and differentiate the clinical presentation of copd exacerbation from other acute respiratory and non‐respiratory syndromes.
Describe the role of diagnostic testing used for evaluation of copd exacerbation.
Distinguish the medical management of patients with copd exacerbation from patients with stable copd.
Describe the evidence based therapies for treatment of copd exacerbations, which may include bronchodilators, systemic corticosteroids, oxygen and antibiotics.
Explain indications, contraindications and mechanisms of action of pharmacologic agents used to treat copd.
Describe and differentiate the means of ventilatory support, including the outcome benefits of non‐invasive positive pressure ventilation in copd exacerbation.
List the indicators of disease severity.
Explain goals for hospital discharge, including specific measures of clinical stability for safe care transition.
SKILLS
Hospitalists should be able to:
Elicit a focused history to identify symptoms consistent with copd exacerbation and etiologic precipitants.
Perform a targeted physical examination to elicit signs consistent with copd exacerbation, differentiate it from other mimicking conditions, and assess severity of illness.
Diagnose patients with copd exacerbation using history, physical examination, and radiographic data.
Select and interpret appropriate diagnostic studies to evaluate severity of copd exacerbation.
Select patients with copd exacerbation who would benefit from use of positive pressure ventilation.
Recognize symptoms, signs and severity of impending respiratory failure and select the indicated evidence based ventilatory approach.
Prescribe appropriate evidence based pharmacologic therapies during copd exacerbation, using the most appropriate route, dose, frequency, and duration of treatment.
Evaluate copd in perioperative risk assessment, recommend measures to optimize perioperative management of copd, and manage post‐operative complications related to underlying copd.
ATTITUDES
Hospitalists should be able to:
Communicate with patients and families to explain the natural history and prognosis of copd.
Communicate with patients and families to explain the goals of care plan, including clinical stability criteria, the importance of prevention measures such as smoking cessation, and required follow‐up care.
Communicate with patients and families to explain discharge medications, potential side effects, duration of therapy and dosing, and taper schedule.
Ensure that prior to discharge patients receive training on proper inhaler techniques and use.
Recognize indications for specialty consultation, which may include pulmonary medicine.
Promote prevention strategies including smoking cessation, indicated vaccinations and vte prophylaxis.
Recognize the potential risks of supplemental oxygen therapy, including development of hypercarbia in patients with chronic respiratory acidosis.
Employ a multidisciplinary approach, which may include pulmonary medicine, respiratory therapy, nursing and social services, to the care of patients with copd exacerbation, beginning at admission and continuing through all care transitions.
Establish and maintain an open dialogue with patients and/or families regarding care goals and limitations, including palliative care and end‐of‐life wishes.
Address resuscitation status early during hospital stay; implement end of life decisions by patients and/or families when indicated or desired.
Collaborate with primary care physicians and emergency physicians in making the admission decisions.
Document treatment plan and discharge instructions, and communicate with the outpatient clinician responsible for follow‐up.
Provide and coordinate resources for patients to ensure the safe transition from the hospital to arranged follow‐up care.
Utilize evidence based recommendations for the treatment of patients with copd exacerbations.
SYSTEM ORGANIZATION AND IMPROVEMENT
To improve efficiency and quality within their organizations, hospitalists should:
Develop educational modules, order sets, and/or pathways that facilitate use of evidence based strategies for copd exacerbation in the emergency department and the hospital, with goals of improving outcomes, decreasing length of stay, and reducing re‐hospitalization rates.
Lead efforts to educate patients and staff on the importance of smoking cessation and other prevention measures.
Lead, coordinate or participate in multidisciplinary initiatives, which may include collaboration with pulmonologists, to promote patient safety and cost‐effective diagnostic and management strategies in the care of patients with copd.
Chronic obstructive pulmonary disease (copd) involves progressive pulmonary airflow limitation that is not completely reversible, and is associated with an abnormal airway inflammatory response. copd affects over 11 million americans and is the fourth most common cause of death in the united states and canada. copd exacerbation is defined as an increase in the usual symptoms of copd and can often result in hospitalization. the diagnosis related group (drg) for copd had 652,000 discharges in 2002, according to the healthcare cost and utilization project (hcup). mean charges for these patients were $13,000 per patient and the mean length‐of‐stay was 4.7 days with in‐hospital mortality of 1.7%. hospitalists use evidence based approaches to optimize care, and can lead multidisciplinary teams to develop institutional guidelines or care pathways to reduce readmission rates and mortality from copd exacerbation.
KNOWLEDGE
Hospitalists should be able to:
Define copd and describe the pathophysiologic processes that lead to small airway obstruction and alveolar destruction.
Describe potential precipitants of exacerbation, including infectious and non‐infectious etiologies.
Recognize and differentiate the clinical presentation of copd exacerbation from other acute respiratory and non‐respiratory syndromes.
Describe the role of diagnostic testing used for evaluation of copd exacerbation.
Distinguish the medical management of patients with copd exacerbation from patients with stable copd.
Describe the evidence based therapies for treatment of copd exacerbations, which may include bronchodilators, systemic corticosteroids, oxygen and antibiotics.
Explain indications, contraindications and mechanisms of action of pharmacologic agents used to treat copd.
Describe and differentiate the means of ventilatory support, including the outcome benefits of non‐invasive positive pressure ventilation in copd exacerbation.
List the indicators of disease severity.
Explain goals for hospital discharge, including specific measures of clinical stability for safe care transition.
SKILLS
Hospitalists should be able to:
Elicit a focused history to identify symptoms consistent with copd exacerbation and etiologic precipitants.
Perform a targeted physical examination to elicit signs consistent with copd exacerbation, differentiate it from other mimicking conditions, and assess severity of illness.
Diagnose patients with copd exacerbation using history, physical examination, and radiographic data.
Select and interpret appropriate diagnostic studies to evaluate severity of copd exacerbation.
Select patients with copd exacerbation who would benefit from use of positive pressure ventilation.
Recognize symptoms, signs and severity of impending respiratory failure and select the indicated evidence based ventilatory approach.
Prescribe appropriate evidence based pharmacologic therapies during copd exacerbation, using the most appropriate route, dose, frequency, and duration of treatment.
Evaluate copd in perioperative risk assessment, recommend measures to optimize perioperative management of copd, and manage post‐operative complications related to underlying copd.
ATTITUDES
Hospitalists should be able to:
Communicate with patients and families to explain the natural history and prognosis of copd.
Communicate with patients and families to explain the goals of care plan, including clinical stability criteria, the importance of prevention measures such as smoking cessation, and required follow‐up care.
Communicate with patients and families to explain discharge medications, potential side effects, duration of therapy and dosing, and taper schedule.
Ensure that prior to discharge patients receive training on proper inhaler techniques and use.
Recognize indications for specialty consultation, which may include pulmonary medicine.
Promote prevention strategies including smoking cessation, indicated vaccinations and vte prophylaxis.
Recognize the potential risks of supplemental oxygen therapy, including development of hypercarbia in patients with chronic respiratory acidosis.
Employ a multidisciplinary approach, which may include pulmonary medicine, respiratory therapy, nursing and social services, to the care of patients with copd exacerbation, beginning at admission and continuing through all care transitions.
Establish and maintain an open dialogue with patients and/or families regarding care goals and limitations, including palliative care and end‐of‐life wishes.
Address resuscitation status early during hospital stay; implement end of life decisions by patients and/or families when indicated or desired.
Collaborate with primary care physicians and emergency physicians in making the admission decisions.
Document treatment plan and discharge instructions, and communicate with the outpatient clinician responsible for follow‐up.
Provide and coordinate resources for patients to ensure the safe transition from the hospital to arranged follow‐up care.
Utilize evidence based recommendations for the treatment of patients with copd exacerbations.
SYSTEM ORGANIZATION AND IMPROVEMENT
To improve efficiency and quality within their organizations, hospitalists should:
Develop educational modules, order sets, and/or pathways that facilitate use of evidence based strategies for copd exacerbation in the emergency department and the hospital, with goals of improving outcomes, decreasing length of stay, and reducing re‐hospitalization rates.
Lead efforts to educate patients and staff on the importance of smoking cessation and other prevention measures.
Lead, coordinate or participate in multidisciplinary initiatives, which may include collaboration with pulmonologists, to promote patient safety and cost‐effective diagnostic and management strategies in the care of patients with copd.
Chronic obstructive pulmonary disease (copd) involves progressive pulmonary airflow limitation that is not completely reversible, and is associated with an abnormal airway inflammatory response. copd affects over 11 million americans and is the fourth most common cause of death in the united states and canada. copd exacerbation is defined as an increase in the usual symptoms of copd and can often result in hospitalization. the diagnosis related group (drg) for copd had 652,000 discharges in 2002, according to the healthcare cost and utilization project (hcup). mean charges for these patients were $13,000 per patient and the mean length‐of‐stay was 4.7 days with in‐hospital mortality of 1.7%. hospitalists use evidence based approaches to optimize care, and can lead multidisciplinary teams to develop institutional guidelines or care pathways to reduce readmission rates and mortality from copd exacerbation.
KNOWLEDGE
Hospitalists should be able to:
Define copd and describe the pathophysiologic processes that lead to small airway obstruction and alveolar destruction.
Describe potential precipitants of exacerbation, including infectious and non‐infectious etiologies.
Recognize and differentiate the clinical presentation of copd exacerbation from other acute respiratory and non‐respiratory syndromes.
Describe the role of diagnostic testing used for evaluation of copd exacerbation.
Distinguish the medical management of patients with copd exacerbation from patients with stable copd.
Describe the evidence based therapies for treatment of copd exacerbations, which may include bronchodilators, systemic corticosteroids, oxygen and antibiotics.
Explain indications, contraindications and mechanisms of action of pharmacologic agents used to treat copd.
Describe and differentiate the means of ventilatory support, including the outcome benefits of non‐invasive positive pressure ventilation in copd exacerbation.
List the indicators of disease severity.
Explain goals for hospital discharge, including specific measures of clinical stability for safe care transition.
SKILLS
Hospitalists should be able to:
Elicit a focused history to identify symptoms consistent with copd exacerbation and etiologic precipitants.
Perform a targeted physical examination to elicit signs consistent with copd exacerbation, differentiate it from other mimicking conditions, and assess severity of illness.
Diagnose patients with copd exacerbation using history, physical examination, and radiographic data.
Select and interpret appropriate diagnostic studies to evaluate severity of copd exacerbation.
Select patients with copd exacerbation who would benefit from use of positive pressure ventilation.
Recognize symptoms, signs and severity of impending respiratory failure and select the indicated evidence based ventilatory approach.
Prescribe appropriate evidence based pharmacologic therapies during copd exacerbation, using the most appropriate route, dose, frequency, and duration of treatment.
Evaluate copd in perioperative risk assessment, recommend measures to optimize perioperative management of copd, and manage post‐operative complications related to underlying copd.
ATTITUDES
Hospitalists should be able to:
Communicate with patients and families to explain the natural history and prognosis of copd.
Communicate with patients and families to explain the goals of care plan, including clinical stability criteria, the importance of prevention measures such as smoking cessation, and required follow‐up care.
Communicate with patients and families to explain discharge medications, potential side effects, duration of therapy and dosing, and taper schedule.
Ensure that prior to discharge patients receive training on proper inhaler techniques and use.
Recognize indications for specialty consultation, which may include pulmonary medicine.
Promote prevention strategies including smoking cessation, indicated vaccinations and vte prophylaxis.
Recognize the potential risks of supplemental oxygen therapy, including development of hypercarbia in patients with chronic respiratory acidosis.
Employ a multidisciplinary approach, which may include pulmonary medicine, respiratory therapy, nursing and social services, to the care of patients with copd exacerbation, beginning at admission and continuing through all care transitions.
Establish and maintain an open dialogue with patients and/or families regarding care goals and limitations, including palliative care and end‐of‐life wishes.
Address resuscitation status early during hospital stay; implement end of life decisions by patients and/or families when indicated or desired.
Collaborate with primary care physicians and emergency physicians in making the admission decisions.
Document treatment plan and discharge instructions, and communicate with the outpatient clinician responsible for follow‐up.
Provide and coordinate resources for patients to ensure the safe transition from the hospital to arranged follow‐up care.
Utilize evidence based recommendations for the treatment of patients with copd exacerbations.
SYSTEM ORGANIZATION AND IMPROVEMENT
To improve efficiency and quality within their organizations, hospitalists should:
Develop educational modules, order sets, and/or pathways that facilitate use of evidence based strategies for copd exacerbation in the emergency department and the hospital, with goals of improving outcomes, decreasing length of stay, and reducing re‐hospitalization rates.
Lead efforts to educate patients and staff on the importance of smoking cessation and other prevention measures.
Lead, coordinate or participate in multidisciplinary initiatives, which may include collaboration with pulmonologists, to promote patient safety and cost‐effective diagnostic and management strategies in the care of patients with copd.
Copyright © 2006 Society of Hospital Medicine
Venous thromboembolism
Venous thromboembolism (VTE), or clotting within the venous system, is a common and under‐recognized cause of significant preventable morbidity and mortality in hospitalized patients. VTE includes deep vein thrombosis (DVT) and pulmonary embolus (PE). The American Heart Association states that first VTE occurs in roughly 100 patients per 100,000 each year. Of these, one‐third have pulmonary embolism. Thirty percent of the 200,000 new cases of VTE annually die within three days, and one‐fifth die suddenly due to pulmonary embolus. DVT accounts for approximately 8,000 hospital discharges per year, while PE accounts for almost 100,000 discharges. Hospitalists can lead their institutions in the development of screening and prevention protocols for patients at risk for VTE, and in the promotion of early diagnosis and safe approaches to the treatment of VTE. Hospitalists can also develop strategies to operationalize cost‐effective programs that will improve patient outcomes and reduce the economic burden of VTE.
KNOWLEDGE
Hospitalists should be able to:
Describe VTE pathophysiology, including contributing aspects of endothelial damage, stasis, and alteration of the coagulation cascade.
Describe the epidemiology of VTE, including the effects of demographic, environmental, thrombophilic, and hormonal factors; underlying medical and surgical conditions, and length of stay.
Explain the clinical presentation of VTE and describe the diagnostic algorithmic approach.
Describe the indications and limitations of specific diagnostic tests, including plasma D‐Dimer testing, Doppler ultrasound, PE‐protocol chest CT, CT of the pelvis and lower extremities, V/Q scanning, and MRI.
Explain when invasive testing, including pulmonary angiography and venography, is indicated and describe the contraindications and potential complications of such testing.
Describe the role of additional tests in the assessment of disease severity, including echocardiogram, troponin, and BNP.
Describe VTE prophylaxis regimens for specific hospitalized risk groups, including medical, general surgical, orthopaedic, neurosurgical, obstetric, ICU, and renal insufficiency patients.
Describe the indications, contraindications and side effects of thrombolytic therapy in the setting of VTE.
Explain indications, contraindications and mechanisms of action of pharmacologic agents used to treat VTE.
Explain the role and potential side effects of other therapeutic modalities in the setting of VTE, including different anticoagulation regimens, IVC filters, and embolectomy.
Describe poor prognostic factors that necessitate early specialty consultation.
Explain the indications for hospitalization and admission to the intensive care unit.
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 relevant risk factors and symptoms consistent with VTE.
Perform a complete physical examination to identify clinical features that predict the presence of VTE and significant clot burden, including evidence of pulmonary hypertension, right heart failure, low perfusion state and underlying malignancy.
Analyze history and physical findings to determine pretest probability for DVT and/or PE.
Apply pretest probability and interpretation of diagnostic testing to establish the diagnosis or exclusion of VTE or need for additional testing strategies.
Determine appropriate level of inpatient care required.
Appraise the need for urgent invasive treatment modalities, including catheter‐directed thrombolysis of the venous or pulmonary artery system, or catheter‐directed or surgical embolectomy.
Formulate a treatment plan tailored to the individual patient, including selection of a specific anticoagulation regimen (agent, dosing, target level and duration) and required monitoring and/or IVC filter placement.
Anticipate and address factors that may complicate the VTE or its management including cardiopulmonary compromise, bleeding and/or anticoagulation failure.
Facilitate co‐management of VTE treatment and prophylaxis when requested by other services.
ATTITUDES
Hospitalists should be able to:
Communicate with patients and families to explain the natural history and prognosis of VTE.
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.
Communicate with patients and families to explain tests and procedures and their indications, and to obtain informed consent.
Recognize the need for early specialty consultation, which may include interventional radiology, vascular surgery, and hematology.
Perform VTE risk assessment in all hospitalized patients and initiate indicated prophylactic measures including pharmacologic agents, mechanical devices and/or ambulation, to reduce the likelihood of VTE.
Educate clinicians and nurses in VTE risk assessment and preventive measures.
Employ a multidisciplinary approach, which may include nursing, anticoagulation, pharmacy and nutrition services, to the care of patients with VTE that begins at admission and continues through all care transitions.
Address and manage pain in patients with VTE.
Collaborate with primary care physicians and emergency physicians in making the admission decision.
Document treatment plan and provide clear discharge instructions for receiving primary care physician responsible for monitoring anticoagulation.
Insure adequate resources, including monitoring of anticoagulation, for patients between hospital discharge and arranged outpatient follow‐up.
Recognize when to prescribe extended duration prophylaxis to patients being discharged to rehabilitation hospitals, skilled nursing facilities, or home with immobility.
Utilize evidence based recommendations when managing hospitalized patients at risk for VTE or with acute VTE.
SYSTEM ORGANIZATION AND IMPROVEMENT
To improve efficiency and quality within their organizations, Hospitalists should:
Lead, coordinate or participate in multidisciplinary initiatives to implement screening and prevention protocols for hospitalized patients based on national evidence based recommendations.
Lead, coordinate or participate in multidisciplinary teams to develop early treatment protocols.
Lead, coordinate or participate in multidisciplinary initiatives to improve inpatient care efficiency, facilitate early discharge, and encourage the outpatient management of VTE.
Advocate for the establishment and support of resources to facilitate early discharge including patient education, adequate availability of pharmacologic agents, and home health resources.
Integrate outcomes research, institution‐specific laboratory policies, and hospital formulary to create indicated and cost‐effective diagnostic and management strategies for patients with VTE.
Venous thromboembolism (VTE), or clotting within the venous system, is a common and under‐recognized cause of significant preventable morbidity and mortality in hospitalized patients. VTE includes deep vein thrombosis (DVT) and pulmonary embolus (PE). The American Heart Association states that first VTE occurs in roughly 100 patients per 100,000 each year. Of these, one‐third have pulmonary embolism. Thirty percent of the 200,000 new cases of VTE annually die within three days, and one‐fifth die suddenly due to pulmonary embolus. DVT accounts for approximately 8,000 hospital discharges per year, while PE accounts for almost 100,000 discharges. Hospitalists can lead their institutions in the development of screening and prevention protocols for patients at risk for VTE, and in the promotion of early diagnosis and safe approaches to the treatment of VTE. Hospitalists can also develop strategies to operationalize cost‐effective programs that will improve patient outcomes and reduce the economic burden of VTE.
KNOWLEDGE
Hospitalists should be able to:
Describe VTE pathophysiology, including contributing aspects of endothelial damage, stasis, and alteration of the coagulation cascade.
Describe the epidemiology of VTE, including the effects of demographic, environmental, thrombophilic, and hormonal factors; underlying medical and surgical conditions, and length of stay.
Explain the clinical presentation of VTE and describe the diagnostic algorithmic approach.
Describe the indications and limitations of specific diagnostic tests, including plasma D‐Dimer testing, Doppler ultrasound, PE‐protocol chest CT, CT of the pelvis and lower extremities, V/Q scanning, and MRI.
Explain when invasive testing, including pulmonary angiography and venography, is indicated and describe the contraindications and potential complications of such testing.
Describe the role of additional tests in the assessment of disease severity, including echocardiogram, troponin, and BNP.
Describe VTE prophylaxis regimens for specific hospitalized risk groups, including medical, general surgical, orthopaedic, neurosurgical, obstetric, ICU, and renal insufficiency patients.
Describe the indications, contraindications and side effects of thrombolytic therapy in the setting of VTE.
Explain indications, contraindications and mechanisms of action of pharmacologic agents used to treat VTE.
Explain the role and potential side effects of other therapeutic modalities in the setting of VTE, including different anticoagulation regimens, IVC filters, and embolectomy.
Describe poor prognostic factors that necessitate early specialty consultation.
Explain the indications for hospitalization and admission to the intensive care unit.
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 relevant risk factors and symptoms consistent with VTE.
Perform a complete physical examination to identify clinical features that predict the presence of VTE and significant clot burden, including evidence of pulmonary hypertension, right heart failure, low perfusion state and underlying malignancy.
Analyze history and physical findings to determine pretest probability for DVT and/or PE.
Apply pretest probability and interpretation of diagnostic testing to establish the diagnosis or exclusion of VTE or need for additional testing strategies.
Determine appropriate level of inpatient care required.
Appraise the need for urgent invasive treatment modalities, including catheter‐directed thrombolysis of the venous or pulmonary artery system, or catheter‐directed or surgical embolectomy.
Formulate a treatment plan tailored to the individual patient, including selection of a specific anticoagulation regimen (agent, dosing, target level and duration) and required monitoring and/or IVC filter placement.
Anticipate and address factors that may complicate the VTE or its management including cardiopulmonary compromise, bleeding and/or anticoagulation failure.
Facilitate co‐management of VTE treatment and prophylaxis when requested by other services.
ATTITUDES
Hospitalists should be able to:
Communicate with patients and families to explain the natural history and prognosis of VTE.
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.
Communicate with patients and families to explain tests and procedures and their indications, and to obtain informed consent.
Recognize the need for early specialty consultation, which may include interventional radiology, vascular surgery, and hematology.
Perform VTE risk assessment in all hospitalized patients and initiate indicated prophylactic measures including pharmacologic agents, mechanical devices and/or ambulation, to reduce the likelihood of VTE.
Educate clinicians and nurses in VTE risk assessment and preventive measures.
Employ a multidisciplinary approach, which may include nursing, anticoagulation, pharmacy and nutrition services, to the care of patients with VTE that begins at admission and continues through all care transitions.
Address and manage pain in patients with VTE.
Collaborate with primary care physicians and emergency physicians in making the admission decision.
Document treatment plan and provide clear discharge instructions for receiving primary care physician responsible for monitoring anticoagulation.
Insure adequate resources, including monitoring of anticoagulation, for patients between hospital discharge and arranged outpatient follow‐up.
Recognize when to prescribe extended duration prophylaxis to patients being discharged to rehabilitation hospitals, skilled nursing facilities, or home with immobility.
Utilize evidence based recommendations when managing hospitalized patients at risk for VTE or with acute VTE.
SYSTEM ORGANIZATION AND IMPROVEMENT
To improve efficiency and quality within their organizations, Hospitalists should:
Lead, coordinate or participate in multidisciplinary initiatives to implement screening and prevention protocols for hospitalized patients based on national evidence based recommendations.
Lead, coordinate or participate in multidisciplinary teams to develop early treatment protocols.
Lead, coordinate or participate in multidisciplinary initiatives to improve inpatient care efficiency, facilitate early discharge, and encourage the outpatient management of VTE.
Advocate for the establishment and support of resources to facilitate early discharge including patient education, adequate availability of pharmacologic agents, and home health resources.
Integrate outcomes research, institution‐specific laboratory policies, and hospital formulary to create indicated and cost‐effective diagnostic and management strategies for patients with VTE.
Venous thromboembolism (VTE), or clotting within the venous system, is a common and under‐recognized cause of significant preventable morbidity and mortality in hospitalized patients. VTE includes deep vein thrombosis (DVT) and pulmonary embolus (PE). The American Heart Association states that first VTE occurs in roughly 100 patients per 100,000 each year. Of these, one‐third have pulmonary embolism. Thirty percent of the 200,000 new cases of VTE annually die within three days, and one‐fifth die suddenly due to pulmonary embolus. DVT accounts for approximately 8,000 hospital discharges per year, while PE accounts for almost 100,000 discharges. Hospitalists can lead their institutions in the development of screening and prevention protocols for patients at risk for VTE, and in the promotion of early diagnosis and safe approaches to the treatment of VTE. Hospitalists can also develop strategies to operationalize cost‐effective programs that will improve patient outcomes and reduce the economic burden of VTE.
KNOWLEDGE
Hospitalists should be able to:
Describe VTE pathophysiology, including contributing aspects of endothelial damage, stasis, and alteration of the coagulation cascade.
Describe the epidemiology of VTE, including the effects of demographic, environmental, thrombophilic, and hormonal factors; underlying medical and surgical conditions, and length of stay.
Explain the clinical presentation of VTE and describe the diagnostic algorithmic approach.
Describe the indications and limitations of specific diagnostic tests, including plasma D‐Dimer testing, Doppler ultrasound, PE‐protocol chest CT, CT of the pelvis and lower extremities, V/Q scanning, and MRI.
Explain when invasive testing, including pulmonary angiography and venography, is indicated and describe the contraindications and potential complications of such testing.
Describe the role of additional tests in the assessment of disease severity, including echocardiogram, troponin, and BNP.
Describe VTE prophylaxis regimens for specific hospitalized risk groups, including medical, general surgical, orthopaedic, neurosurgical, obstetric, ICU, and renal insufficiency patients.
Describe the indications, contraindications and side effects of thrombolytic therapy in the setting of VTE.
Explain indications, contraindications and mechanisms of action of pharmacologic agents used to treat VTE.
Explain the role and potential side effects of other therapeutic modalities in the setting of VTE, including different anticoagulation regimens, IVC filters, and embolectomy.
Describe poor prognostic factors that necessitate early specialty consultation.
Explain the indications for hospitalization and admission to the intensive care unit.
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 relevant risk factors and symptoms consistent with VTE.
Perform a complete physical examination to identify clinical features that predict the presence of VTE and significant clot burden, including evidence of pulmonary hypertension, right heart failure, low perfusion state and underlying malignancy.
Analyze history and physical findings to determine pretest probability for DVT and/or PE.
Apply pretest probability and interpretation of diagnostic testing to establish the diagnosis or exclusion of VTE or need for additional testing strategies.
Determine appropriate level of inpatient care required.
Appraise the need for urgent invasive treatment modalities, including catheter‐directed thrombolysis of the venous or pulmonary artery system, or catheter‐directed or surgical embolectomy.
Formulate a treatment plan tailored to the individual patient, including selection of a specific anticoagulation regimen (agent, dosing, target level and duration) and required monitoring and/or IVC filter placement.
Anticipate and address factors that may complicate the VTE or its management including cardiopulmonary compromise, bleeding and/or anticoagulation failure.
Facilitate co‐management of VTE treatment and prophylaxis when requested by other services.
ATTITUDES
Hospitalists should be able to:
Communicate with patients and families to explain the natural history and prognosis of VTE.
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.
Communicate with patients and families to explain tests and procedures and their indications, and to obtain informed consent.
Recognize the need for early specialty consultation, which may include interventional radiology, vascular surgery, and hematology.
Perform VTE risk assessment in all hospitalized patients and initiate indicated prophylactic measures including pharmacologic agents, mechanical devices and/or ambulation, to reduce the likelihood of VTE.
Educate clinicians and nurses in VTE risk assessment and preventive measures.
Employ a multidisciplinary approach, which may include nursing, anticoagulation, pharmacy and nutrition services, to the care of patients with VTE that begins at admission and continues through all care transitions.
Address and manage pain in patients with VTE.
Collaborate with primary care physicians and emergency physicians in making the admission decision.
Document treatment plan and provide clear discharge instructions for receiving primary care physician responsible for monitoring anticoagulation.
Insure adequate resources, including monitoring of anticoagulation, for patients between hospital discharge and arranged outpatient follow‐up.
Recognize when to prescribe extended duration prophylaxis to patients being discharged to rehabilitation hospitals, skilled nursing facilities, or home with immobility.
Utilize evidence based recommendations when managing hospitalized patients at risk for VTE or with acute VTE.
SYSTEM ORGANIZATION AND IMPROVEMENT
To improve efficiency and quality within their organizations, Hospitalists should:
Lead, coordinate or participate in multidisciplinary initiatives to implement screening and prevention protocols for hospitalized patients based on national evidence based recommendations.
Lead, coordinate or participate in multidisciplinary teams to develop early treatment protocols.
Lead, coordinate or participate in multidisciplinary initiatives to improve inpatient care efficiency, facilitate early discharge, and encourage the outpatient management of VTE.
Advocate for the establishment and support of resources to facilitate early discharge including patient education, adequate availability of pharmacologic agents, and home health resources.
Integrate outcomes research, institution‐specific laboratory policies, and hospital formulary to create indicated and cost‐effective diagnostic and management strategies for patients with VTE.
Copyright © 2006 Society of Hospital Medicine
Introduction to the core competencies in hospital medicine
Background
Hospital Medicine is emerging as the next generation of the site‐defined specialties, following Emergency Medicine and Critical Care Medicine. The Society of Hospital Medicine estimates the need for 20,000‐30,000 practicing hospitalists in the next five to ten years. A variety of changes in healthcare delivery system and residency training programs has spurred this development. However, this growth has occurred in the absence of any standards of what knowledge, skills and attitudes a hospitalist must possess to successfully practice Hospital Medicine.
The publication of The Core Competencies in Hospital Medicine: A Framework for Curriculum Development by the Society of Hospital Medicine (The Core Competencies) represents the first attempt to define the specialty of Hospital Medicine. The Core Competencies culminates approximately four years of thoughtful research, planning, and development. The Core Competencies are a result of the contributions of over one hundred hospitalists and other content experts, under the guidance and leadership of the SHM Core Curriculum Task Force and Editorial Board. Task Force members were chosen from university and community hospitals, teaching and non‐teaching programs, for‐ and not‐for‐profit programs, and from all geographic regions of the United States to ensure broad representation of practicing hospitalists and SHM membership. A companion article to this supplement (Dressler DD, Pistoria MJ, Budnitz TL, McKean SCW, Amin AN. Core competencies in hospital medicine: development and methodology. J Hosp Med. 2006;1:48‐56) details the project methodology.
Purpose
The Core Competencies provide a framework for professional and curricular development based on a shared understanding of the essential knowledge, skills and attitudes expected of physicians working as hospitalists. The Core Competencies document specifically targets directors of continuing medical education (CME), Hospitalist programs and fellowships, residency programs, and medical school internal medicine clerkships. The goal is to standardize the expectations for training and professional development and to facilitate the development of curricula. The competencies were written to reflect learning outcomes, not convey specific content. They can be used to establish targets for learning outcomes. With these targets in mind, instructors can select content and instructional methods and shape the curricula based on the unique characteristics of the intended learners and learning context. A second companion article to the Core Competencies (McKean SCW, Budnitz TL, Dressler DD, Amin AN, Pistoria MJ. How to use The Core Competencies in Hospital Medicine: A Framework for Curriculum Development. J Hosp Med. 2006;1:57‐67) details how the competencies can be utilized to develop training and curricula to solve specific problems within an institution.
Organization Structure
The Core Competencies comprise three sectionsClinical Conditions, Procedures and Healthcare Systems. Within each section, individual chapters present competencies as three domains of educational outcomes: the Cognitive domain (Knowledge), the Psychomotor domain (Skills), and the Affective domain (Attitudes). The competencies have been carefully crafted as learning outcomes to indicate a specific, measurable level of proficiency that should be expected. Each chapter of the Clinical Conditions and Procedures sections also includes a Systems Organization and Improvement subsection. Outcome statements in this subsection possess attributes of each domain and indicate how the role of hospitalists should evolve. These outcome statements also acknowledge the current variance of responsibilities related to leading, coordinating or participating in the assessment, development or implementation of system improvements. More than any particular knowledge or skill, this systems approach distinguishes a hospitalist from other clinicians practicing in the hospital.
Conclusion
The educational strategy of the Society of Hospital Medicine was to stress the key concepts in hospital medicine in this first edition that would provide a framework for the development of timely, context‐specific training and curricula to meet the evolving needs of practicing hospitalists. Therefore, the Task Force selected to include the most commonly encountered clinical conditions, procedures, and healthcare systems that are central to the practice of Hospital Medicine today. We anticipate that future editions will build upon The Core Competencies with additional chapters and revisions to reflect feedback from its users, formal evaluation of its application and advances in the field of hospital medicine.
It is our goal that The Core Competencies in Hospital Medicine serve as a valuable resource. For the practicing hospitalist, it should aid the refinement of skills and assist in institutional program development. For residency program directors and clerkship directors, the chapters can function as a guide in curriculum development for inpatient medicine rotations or in meeting some of the Accreditation Council on Graduate Medical Education's Outcomes Project. Lastly, for those developing continuing medical education programs, The Core Competencies should serve as an outline around which educational programs can be developed.
The Core Curriculum Task Force Editorial Board
Michael J. Pistoria, DO, FACP (Chair)
Alpesh N. Amin, MD, MBA, FACP
Daniel D. Dressler, MD, MSc
Sylvia C. W. McKean, MD
Tina L. Budnitz, MPH
Background
Hospital Medicine is emerging as the next generation of the site‐defined specialties, following Emergency Medicine and Critical Care Medicine. The Society of Hospital Medicine estimates the need for 20,000‐30,000 practicing hospitalists in the next five to ten years. A variety of changes in healthcare delivery system and residency training programs has spurred this development. However, this growth has occurred in the absence of any standards of what knowledge, skills and attitudes a hospitalist must possess to successfully practice Hospital Medicine.
The publication of The Core Competencies in Hospital Medicine: A Framework for Curriculum Development by the Society of Hospital Medicine (The Core Competencies) represents the first attempt to define the specialty of Hospital Medicine. The Core Competencies culminates approximately four years of thoughtful research, planning, and development. The Core Competencies are a result of the contributions of over one hundred hospitalists and other content experts, under the guidance and leadership of the SHM Core Curriculum Task Force and Editorial Board. Task Force members were chosen from university and community hospitals, teaching and non‐teaching programs, for‐ and not‐for‐profit programs, and from all geographic regions of the United States to ensure broad representation of practicing hospitalists and SHM membership. A companion article to this supplement (Dressler DD, Pistoria MJ, Budnitz TL, McKean SCW, Amin AN. Core competencies in hospital medicine: development and methodology. J Hosp Med. 2006;1:48‐56) details the project methodology.
Purpose
The Core Competencies provide a framework for professional and curricular development based on a shared understanding of the essential knowledge, skills and attitudes expected of physicians working as hospitalists. The Core Competencies document specifically targets directors of continuing medical education (CME), Hospitalist programs and fellowships, residency programs, and medical school internal medicine clerkships. The goal is to standardize the expectations for training and professional development and to facilitate the development of curricula. The competencies were written to reflect learning outcomes, not convey specific content. They can be used to establish targets for learning outcomes. With these targets in mind, instructors can select content and instructional methods and shape the curricula based on the unique characteristics of the intended learners and learning context. A second companion article to the Core Competencies (McKean SCW, Budnitz TL, Dressler DD, Amin AN, Pistoria MJ. How to use The Core Competencies in Hospital Medicine: A Framework for Curriculum Development. J Hosp Med. 2006;1:57‐67) details how the competencies can be utilized to develop training and curricula to solve specific problems within an institution.
Organization Structure
The Core Competencies comprise three sectionsClinical Conditions, Procedures and Healthcare Systems. Within each section, individual chapters present competencies as three domains of educational outcomes: the Cognitive domain (Knowledge), the Psychomotor domain (Skills), and the Affective domain (Attitudes). The competencies have been carefully crafted as learning outcomes to indicate a specific, measurable level of proficiency that should be expected. Each chapter of the Clinical Conditions and Procedures sections also includes a Systems Organization and Improvement subsection. Outcome statements in this subsection possess attributes of each domain and indicate how the role of hospitalists should evolve. These outcome statements also acknowledge the current variance of responsibilities related to leading, coordinating or participating in the assessment, development or implementation of system improvements. More than any particular knowledge or skill, this systems approach distinguishes a hospitalist from other clinicians practicing in the hospital.
Conclusion
The educational strategy of the Society of Hospital Medicine was to stress the key concepts in hospital medicine in this first edition that would provide a framework for the development of timely, context‐specific training and curricula to meet the evolving needs of practicing hospitalists. Therefore, the Task Force selected to include the most commonly encountered clinical conditions, procedures, and healthcare systems that are central to the practice of Hospital Medicine today. We anticipate that future editions will build upon The Core Competencies with additional chapters and revisions to reflect feedback from its users, formal evaluation of its application and advances in the field of hospital medicine.
It is our goal that The Core Competencies in Hospital Medicine serve as a valuable resource. For the practicing hospitalist, it should aid the refinement of skills and assist in institutional program development. For residency program directors and clerkship directors, the chapters can function as a guide in curriculum development for inpatient medicine rotations or in meeting some of the Accreditation Council on Graduate Medical Education's Outcomes Project. Lastly, for those developing continuing medical education programs, The Core Competencies should serve as an outline around which educational programs can be developed.
The Core Curriculum Task Force Editorial Board
Michael J. Pistoria, DO, FACP (Chair)
Alpesh N. Amin, MD, MBA, FACP
Daniel D. Dressler, MD, MSc
Sylvia C. W. McKean, MD
Tina L. Budnitz, MPH
Background
Hospital Medicine is emerging as the next generation of the site‐defined specialties, following Emergency Medicine and Critical Care Medicine. The Society of Hospital Medicine estimates the need for 20,000‐30,000 practicing hospitalists in the next five to ten years. A variety of changes in healthcare delivery system and residency training programs has spurred this development. However, this growth has occurred in the absence of any standards of what knowledge, skills and attitudes a hospitalist must possess to successfully practice Hospital Medicine.
The publication of The Core Competencies in Hospital Medicine: A Framework for Curriculum Development by the Society of Hospital Medicine (The Core Competencies) represents the first attempt to define the specialty of Hospital Medicine. The Core Competencies culminates approximately four years of thoughtful research, planning, and development. The Core Competencies are a result of the contributions of over one hundred hospitalists and other content experts, under the guidance and leadership of the SHM Core Curriculum Task Force and Editorial Board. Task Force members were chosen from university and community hospitals, teaching and non‐teaching programs, for‐ and not‐for‐profit programs, and from all geographic regions of the United States to ensure broad representation of practicing hospitalists and SHM membership. A companion article to this supplement (Dressler DD, Pistoria MJ, Budnitz TL, McKean SCW, Amin AN. Core competencies in hospital medicine: development and methodology. J Hosp Med. 2006;1:48‐56) details the project methodology.
Purpose
The Core Competencies provide a framework for professional and curricular development based on a shared understanding of the essential knowledge, skills and attitudes expected of physicians working as hospitalists. The Core Competencies document specifically targets directors of continuing medical education (CME), Hospitalist programs and fellowships, residency programs, and medical school internal medicine clerkships. The goal is to standardize the expectations for training and professional development and to facilitate the development of curricula. The competencies were written to reflect learning outcomes, not convey specific content. They can be used to establish targets for learning outcomes. With these targets in mind, instructors can select content and instructional methods and shape the curricula based on the unique characteristics of the intended learners and learning context. A second companion article to the Core Competencies (McKean SCW, Budnitz TL, Dressler DD, Amin AN, Pistoria MJ. How to use The Core Competencies in Hospital Medicine: A Framework for Curriculum Development. J Hosp Med. 2006;1:57‐67) details how the competencies can be utilized to develop training and curricula to solve specific problems within an institution.
Organization Structure
The Core Competencies comprise three sectionsClinical Conditions, Procedures and Healthcare Systems. Within each section, individual chapters present competencies as three domains of educational outcomes: the Cognitive domain (Knowledge), the Psychomotor domain (Skills), and the Affective domain (Attitudes). The competencies have been carefully crafted as learning outcomes to indicate a specific, measurable level of proficiency that should be expected. Each chapter of the Clinical Conditions and Procedures sections also includes a Systems Organization and Improvement subsection. Outcome statements in this subsection possess attributes of each domain and indicate how the role of hospitalists should evolve. These outcome statements also acknowledge the current variance of responsibilities related to leading, coordinating or participating in the assessment, development or implementation of system improvements. More than any particular knowledge or skill, this systems approach distinguishes a hospitalist from other clinicians practicing in the hospital.
Conclusion
The educational strategy of the Society of Hospital Medicine was to stress the key concepts in hospital medicine in this first edition that would provide a framework for the development of timely, context‐specific training and curricula to meet the evolving needs of practicing hospitalists. Therefore, the Task Force selected to include the most commonly encountered clinical conditions, procedures, and healthcare systems that are central to the practice of Hospital Medicine today. We anticipate that future editions will build upon The Core Competencies with additional chapters and revisions to reflect feedback from its users, formal evaluation of its application and advances in the field of hospital medicine.
It is our goal that The Core Competencies in Hospital Medicine serve as a valuable resource. For the practicing hospitalist, it should aid the refinement of skills and assist in institutional program development. For residency program directors and clerkship directors, the chapters can function as a guide in curriculum development for inpatient medicine rotations or in meeting some of the Accreditation Council on Graduate Medical Education's Outcomes Project. Lastly, for those developing continuing medical education programs, The Core Competencies should serve as an outline around which educational programs can be developed.
The Core Curriculum Task Force Editorial Board
Michael J. Pistoria, DO, FACP (Chair)
Alpesh N. Amin, MD, MBA, FACP
Daniel D. Dressler, MD, MSc
Sylvia C. W. McKean, MD
Tina L. Budnitz, MPH
Copyright © 2006 Society of Hospital Medicine
Care of vulnerable populations
Vulnerable populations are defined as groups who are at increased risk of receiving a disparity in medical care on the basis of financial circumstances or social characteristics such as age, race, gender, ethnicity, sexual orientation, spirituality, disability, or socioeconomic or insurance status. Hospitalists may play a significant role in influencing the health status, health care access, and health care delivery to vulnerable populations due to their higher rates of hospital utilization and lower access to outpatient care. Agency for Healthcare Research and Quality (AHRQ) estimates health expenditures due to low health literacy range from $29 billion to $69 billion per year. Death rates per 1,000 admissions in low mortality Diagnosis Related Groups (DRG) are higher for hispanics (0.65), blacks (0.71) and the uninsured (1.1) compared to whites (0.61) and the privately insured (0.61). The Nationwide Inpatient Sample (NIS) benchmark mortality in low mortality DRGs is less than 0.5%. Hospitalists may serve as initial points of contact for the health care of these groups. Core competencies in communication, advocacy and comprehension of the health care needs of vulnerable populations may influence healthcare expenditures, morbidity and mortality. Hospitalists can lead initiatives that promote equity of healthcare provision.
KNOWLEDGE
Hospitalists should be able to:
Explain key factors leading to disparities in health status among specific vulnerable populations.
Explain disease processes that disproportionately affect vulnerable populations.
Describe key factors leading to disparities in the quality of care provided to vulnerable groups.
List services in local healthcare system designed to ameliorate barriers to care provision.
Name local and institutional resources available to patients needing financial assistance.
Identify key elements of discharge planning for uninsured, underinsured, and disabled patients.
SKILLS
Hospitalists should be able to:
Elicit elements of the history and physical examination to detect illnesses for which vulnerable populations may have increased risk.
Elicit a social history to assess patient habits, identify patients at risk for breaks in transitions of care, and clarify patient values around treatment options.
Tailor the therapeutic plan that takes into account discharge plan and outpatient resources.
Identify vulnerable patients whose outpatient environment might benefit from additional community resources.
Target vulnerable groups for indicated vaccinations and preventive care services or referrals.
ATTITUDES
Hospitalists should be able to:
Utilize appropriate educational resources to inform vulnerable patients with low health literacy.
Provide education and systems interventions to minimize medication errors in patients with low health literacy.
Communicate openly to facilitate trust in patient‐physician interactions.
Actively involve patients and families in the design of care plans.
Secure translators to assist with interviewing, physical examination, and medical decision making.
Facilitate communication between vulnerable patient groups and consultants.
Provide leadership to foster attitudes and systems improvements that promote quality health care provision to vulnerable populations.
Connect vulnerable 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.
Coordinate adequate transitions of care from the inpatient to outpatient setting.
Communicate with primary care physicians to facilitate transitions of care.
Vulnerable populations are defined as groups who are at increased risk of receiving a disparity in medical care on the basis of financial circumstances or social characteristics such as age, race, gender, ethnicity, sexual orientation, spirituality, disability, or socioeconomic or insurance status. Hospitalists may play a significant role in influencing the health status, health care access, and health care delivery to vulnerable populations due to their higher rates of hospital utilization and lower access to outpatient care. Agency for Healthcare Research and Quality (AHRQ) estimates health expenditures due to low health literacy range from $29 billion to $69 billion per year. Death rates per 1,000 admissions in low mortality Diagnosis Related Groups (DRG) are higher for hispanics (0.65), blacks (0.71) and the uninsured (1.1) compared to whites (0.61) and the privately insured (0.61). The Nationwide Inpatient Sample (NIS) benchmark mortality in low mortality DRGs is less than 0.5%. Hospitalists may serve as initial points of contact for the health care of these groups. Core competencies in communication, advocacy and comprehension of the health care needs of vulnerable populations may influence healthcare expenditures, morbidity and mortality. Hospitalists can lead initiatives that promote equity of healthcare provision.
KNOWLEDGE
Hospitalists should be able to:
Explain key factors leading to disparities in health status among specific vulnerable populations.
Explain disease processes that disproportionately affect vulnerable populations.
Describe key factors leading to disparities in the quality of care provided to vulnerable groups.
List services in local healthcare system designed to ameliorate barriers to care provision.
Name local and institutional resources available to patients needing financial assistance.
Identify key elements of discharge planning for uninsured, underinsured, and disabled patients.
SKILLS
Hospitalists should be able to:
Elicit elements of the history and physical examination to detect illnesses for which vulnerable populations may have increased risk.
Elicit a social history to assess patient habits, identify patients at risk for breaks in transitions of care, and clarify patient values around treatment options.
Tailor the therapeutic plan that takes into account discharge plan and outpatient resources.
Identify vulnerable patients whose outpatient environment might benefit from additional community resources.
Target vulnerable groups for indicated vaccinations and preventive care services or referrals.
ATTITUDES
Hospitalists should be able to:
Utilize appropriate educational resources to inform vulnerable patients with low health literacy.
Provide education and systems interventions to minimize medication errors in patients with low health literacy.
Communicate openly to facilitate trust in patient‐physician interactions.
Actively involve patients and families in the design of care plans.
Secure translators to assist with interviewing, physical examination, and medical decision making.
Facilitate communication between vulnerable patient groups and consultants.
Provide leadership to foster attitudes and systems improvements that promote quality health care provision to vulnerable populations.
Connect vulnerable 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.
Coordinate adequate transitions of care from the inpatient to outpatient setting.
Communicate with primary care physicians to facilitate transitions of care.
Vulnerable populations are defined as groups who are at increased risk of receiving a disparity in medical care on the basis of financial circumstances or social characteristics such as age, race, gender, ethnicity, sexual orientation, spirituality, disability, or socioeconomic or insurance status. Hospitalists may play a significant role in influencing the health status, health care access, and health care delivery to vulnerable populations due to their higher rates of hospital utilization and lower access to outpatient care. Agency for Healthcare Research and Quality (AHRQ) estimates health expenditures due to low health literacy range from $29 billion to $69 billion per year. Death rates per 1,000 admissions in low mortality Diagnosis Related Groups (DRG) are higher for hispanics (0.65), blacks (0.71) and the uninsured (1.1) compared to whites (0.61) and the privately insured (0.61). The Nationwide Inpatient Sample (NIS) benchmark mortality in low mortality DRGs is less than 0.5%. Hospitalists may serve as initial points of contact for the health care of these groups. Core competencies in communication, advocacy and comprehension of the health care needs of vulnerable populations may influence healthcare expenditures, morbidity and mortality. Hospitalists can lead initiatives that promote equity of healthcare provision.
KNOWLEDGE
Hospitalists should be able to:
Explain key factors leading to disparities in health status among specific vulnerable populations.
Explain disease processes that disproportionately affect vulnerable populations.
Describe key factors leading to disparities in the quality of care provided to vulnerable groups.
List services in local healthcare system designed to ameliorate barriers to care provision.
Name local and institutional resources available to patients needing financial assistance.
Identify key elements of discharge planning for uninsured, underinsured, and disabled patients.
SKILLS
Hospitalists should be able to:
Elicit elements of the history and physical examination to detect illnesses for which vulnerable populations may have increased risk.
Elicit a social history to assess patient habits, identify patients at risk for breaks in transitions of care, and clarify patient values around treatment options.
Tailor the therapeutic plan that takes into account discharge plan and outpatient resources.
Identify vulnerable patients whose outpatient environment might benefit from additional community resources.
Target vulnerable groups for indicated vaccinations and preventive care services or referrals.
ATTITUDES
Hospitalists should be able to:
Utilize appropriate educational resources to inform vulnerable patients with low health literacy.
Provide education and systems interventions to minimize medication errors in patients with low health literacy.
Communicate openly to facilitate trust in patient‐physician interactions.
Actively involve patients and families in the design of care plans.
Secure translators to assist with interviewing, physical examination, and medical decision making.
Facilitate communication between vulnerable patient groups and consultants.
Provide leadership to foster attitudes and systems improvements that promote quality health care provision to vulnerable populations.
Connect vulnerable 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.
Coordinate adequate transitions of care from the inpatient to outpatient setting.
Communicate with primary care physicians to facilitate transitions of care.
Copyright © 2006 Society of Hospital Medicine
The Core Competencies in Hospital Medicine
Asthma involves bronchospasm with reversible airflow limitation and an abnormal airway inflammatory response. The Healthcare Cost and Utilization Project (HCUP) estimates 130,000 hospital discharges for asthma in 2002. The mean length‐of‐stay was 2.8 days, with mean charges of $8,000 per patient. When viewed as part of the Diagnosis Related Group (DRG) for Chronic Obstructive Pulmonary Disease, the data is slightly different. These patients accounted for 85,000 discharges with mean charges of almost $14,000 per patient. The mean length‐of‐stay was 4.6 days in this group, with an in‐hospital mortality of 0.6%. Hospitalists use evidence based approaches to optimize care of patients with asthma exacerbation. Hospitalists lead multidisciplinary teams to develop institutional guidelines or care pathways to improve efficiency and quality of care and to reduce readmission rates.
KNOWLEDGE
Hospitalists should be able to:
Define asthma and describe the pathophysiologic processes that lead to reversible airway obstruction and inflammation.
Identify precipitants of asthma exacerbation.
Recognize and differentiate the clinical presentation of asthma exacerbation from other acute respiratory and non‐respiratory syndromes.
Describe the role of diagnostic testing, including peak flow monitoring, used for evaluation of asthma exacerbation.
Describe evidence based therapies for the treatment of asthma exacerbations, which may include bronchodilators, systemic corticosteroids, and oxygen.
Explain indications, contraindications and mechanisms of action of pharmacologic agents used to treat asthma.
Explain the indications for invasive ventilatory support.
List the risk factors for disease severity and death from asthma.
Explain goals for hospital discharge, including specific measures of clinical stability for safe care transition.
SKILLS
Hospitalists should be able to:
Elicit a focused history to identify triggers of asthma and symptoms consistent with asthma exacerbation.
Perform a targeted physical examination to elicit signs consistent with asthma exacerbation, differentiate findings from other mimicking conditions, and assess severity of illness.
Select and interpret appropriate diagnostic studies to evaluate severity of asthma exacerbation.
Recognize impending respiratory failure and coordinate intubation when indicated.
Prescribe appropriate evidence based pharmacologic therapies during asthma exacerbation, using the most appropriate route, dose, frequency and duration of treatment.
ATTITUDES
Hospitalists should be able to:
Communicate with patients and families to explain the natural history and prognosis of asthma.
Communicate with patients and families to explain the goals of care plan, including clinical stability criteria, the importance of prevention measures such as smoking cessation and modification of environmental exposures, and required follow‐up care.
Communicate with patients and families to explain discharge medications, potential side effects, duration of therapy and dosing, and taper schedule.
Ensure that prior to discharge, patients receive training of proper inhaler and peak flow techniques.
Differentiate for patients and families the indications and appropriate use of daily use inhalers and rescue inhalers for asthmatic control.
Communicate with patients and families to explain symptoms and signs that should prompt emergent medical management.
Recognize indications for specialty consultation, including pulmonary and allergy medicine.
Promote prevention strategies including smoking cessation and indicated vaccinations.
Employ a multidisciplinary approach, which may include pulmonary medicine, respiratory therapy, nursing and social services, to the care of patients with asthma exacerbation.
Collaborate with primary care physicians and emergency physicians in making the admission decision.
Document treatment plan and discharge instructions, and communicate with the outpatient clinician responsible for follow‐up.
Provide and coordinate resources for patients to ensure safe transition from the hospital to arranged follow‐up care.
Utilize evidence based recommendations for the treatment of patients with asthma exacerbations.
SYSTEM ORGANIZATION AND IMPROVEMENT
To improve efficiency and quality within their organizations, Hospitalists should:
Develop educational modules, order sets, and/or pathways that facilitate use of evidence based strategies for asthma exacerbation in the emergency department and the hospital, with goals of improving outcomes, decreasing length of stay, and reducing re‐hospitalization rates.
Lead efforts to educate staff on the importance of smoking cessation counseling and other prevention measures.
Lead, coordinate or participate in multidisciplinary initiatives, which may include collaborative efforts with pulmonologists, to promote patient safety and optimize cost‐effective diagnostic and management strategies for patients with asthma.
Asthma involves bronchospasm with reversible airflow limitation and an abnormal airway inflammatory response. The Healthcare Cost and Utilization Project (HCUP) estimates 130,000 hospital discharges for asthma in 2002. The mean length‐of‐stay was 2.8 days, with mean charges of $8,000 per patient. When viewed as part of the Diagnosis Related Group (DRG) for Chronic Obstructive Pulmonary Disease, the data is slightly different. These patients accounted for 85,000 discharges with mean charges of almost $14,000 per patient. The mean length‐of‐stay was 4.6 days in this group, with an in‐hospital mortality of 0.6%. Hospitalists use evidence based approaches to optimize care of patients with asthma exacerbation. Hospitalists lead multidisciplinary teams to develop institutional guidelines or care pathways to improve efficiency and quality of care and to reduce readmission rates.
KNOWLEDGE
Hospitalists should be able to:
Define asthma and describe the pathophysiologic processes that lead to reversible airway obstruction and inflammation.
Identify precipitants of asthma exacerbation.
Recognize and differentiate the clinical presentation of asthma exacerbation from other acute respiratory and non‐respiratory syndromes.
Describe the role of diagnostic testing, including peak flow monitoring, used for evaluation of asthma exacerbation.
Describe evidence based therapies for the treatment of asthma exacerbations, which may include bronchodilators, systemic corticosteroids, and oxygen.
Explain indications, contraindications and mechanisms of action of pharmacologic agents used to treat asthma.
Explain the indications for invasive ventilatory support.
List the risk factors for disease severity and death from asthma.
Explain goals for hospital discharge, including specific measures of clinical stability for safe care transition.
SKILLS
Hospitalists should be able to:
Elicit a focused history to identify triggers of asthma and symptoms consistent with asthma exacerbation.
Perform a targeted physical examination to elicit signs consistent with asthma exacerbation, differentiate findings from other mimicking conditions, and assess severity of illness.
Select and interpret appropriate diagnostic studies to evaluate severity of asthma exacerbation.
Recognize impending respiratory failure and coordinate intubation when indicated.
Prescribe appropriate evidence based pharmacologic therapies during asthma exacerbation, using the most appropriate route, dose, frequency and duration of treatment.
ATTITUDES
Hospitalists should be able to:
Communicate with patients and families to explain the natural history and prognosis of asthma.
Communicate with patients and families to explain the goals of care plan, including clinical stability criteria, the importance of prevention measures such as smoking cessation and modification of environmental exposures, and required follow‐up care.
Communicate with patients and families to explain discharge medications, potential side effects, duration of therapy and dosing, and taper schedule.
Ensure that prior to discharge, patients receive training of proper inhaler and peak flow techniques.
Differentiate for patients and families the indications and appropriate use of daily use inhalers and rescue inhalers for asthmatic control.
Communicate with patients and families to explain symptoms and signs that should prompt emergent medical management.
Recognize indications for specialty consultation, including pulmonary and allergy medicine.
Promote prevention strategies including smoking cessation and indicated vaccinations.
Employ a multidisciplinary approach, which may include pulmonary medicine, respiratory therapy, nursing and social services, to the care of patients with asthma exacerbation.
Collaborate with primary care physicians and emergency physicians in making the admission decision.
Document treatment plan and discharge instructions, and communicate with the outpatient clinician responsible for follow‐up.
Provide and coordinate resources for patients to ensure safe transition from the hospital to arranged follow‐up care.
Utilize evidence based recommendations for the treatment of patients with asthma exacerbations.
SYSTEM ORGANIZATION AND IMPROVEMENT
To improve efficiency and quality within their organizations, Hospitalists should:
Develop educational modules, order sets, and/or pathways that facilitate use of evidence based strategies for asthma exacerbation in the emergency department and the hospital, with goals of improving outcomes, decreasing length of stay, and reducing re‐hospitalization rates.
Lead efforts to educate staff on the importance of smoking cessation counseling and other prevention measures.
Lead, coordinate or participate in multidisciplinary initiatives, which may include collaborative efforts with pulmonologists, to promote patient safety and optimize cost‐effective diagnostic and management strategies for patients with asthma.
Asthma involves bronchospasm with reversible airflow limitation and an abnormal airway inflammatory response. The Healthcare Cost and Utilization Project (HCUP) estimates 130,000 hospital discharges for asthma in 2002. The mean length‐of‐stay was 2.8 days, with mean charges of $8,000 per patient. When viewed as part of the Diagnosis Related Group (DRG) for Chronic Obstructive Pulmonary Disease, the data is slightly different. These patients accounted for 85,000 discharges with mean charges of almost $14,000 per patient. The mean length‐of‐stay was 4.6 days in this group, with an in‐hospital mortality of 0.6%. Hospitalists use evidence based approaches to optimize care of patients with asthma exacerbation. Hospitalists lead multidisciplinary teams to develop institutional guidelines or care pathways to improve efficiency and quality of care and to reduce readmission rates.
KNOWLEDGE
Hospitalists should be able to:
Define asthma and describe the pathophysiologic processes that lead to reversible airway obstruction and inflammation.
Identify precipitants of asthma exacerbation.
Recognize and differentiate the clinical presentation of asthma exacerbation from other acute respiratory and non‐respiratory syndromes.
Describe the role of diagnostic testing, including peak flow monitoring, used for evaluation of asthma exacerbation.
Describe evidence based therapies for the treatment of asthma exacerbations, which may include bronchodilators, systemic corticosteroids, and oxygen.
Explain indications, contraindications and mechanisms of action of pharmacologic agents used to treat asthma.
Explain the indications for invasive ventilatory support.
List the risk factors for disease severity and death from asthma.
Explain goals for hospital discharge, including specific measures of clinical stability for safe care transition.
SKILLS
Hospitalists should be able to:
Elicit a focused history to identify triggers of asthma and symptoms consistent with asthma exacerbation.
Perform a targeted physical examination to elicit signs consistent with asthma exacerbation, differentiate findings from other mimicking conditions, and assess severity of illness.
Select and interpret appropriate diagnostic studies to evaluate severity of asthma exacerbation.
Recognize impending respiratory failure and coordinate intubation when indicated.
Prescribe appropriate evidence based pharmacologic therapies during asthma exacerbation, using the most appropriate route, dose, frequency and duration of treatment.
ATTITUDES
Hospitalists should be able to:
Communicate with patients and families to explain the natural history and prognosis of asthma.
Communicate with patients and families to explain the goals of care plan, including clinical stability criteria, the importance of prevention measures such as smoking cessation and modification of environmental exposures, and required follow‐up care.
Communicate with patients and families to explain discharge medications, potential side effects, duration of therapy and dosing, and taper schedule.
Ensure that prior to discharge, patients receive training of proper inhaler and peak flow techniques.
Differentiate for patients and families the indications and appropriate use of daily use inhalers and rescue inhalers for asthmatic control.
Communicate with patients and families to explain symptoms and signs that should prompt emergent medical management.
Recognize indications for specialty consultation, including pulmonary and allergy medicine.
Promote prevention strategies including smoking cessation and indicated vaccinations.
Employ a multidisciplinary approach, which may include pulmonary medicine, respiratory therapy, nursing and social services, to the care of patients with asthma exacerbation.
Collaborate with primary care physicians and emergency physicians in making the admission decision.
Document treatment plan and discharge instructions, and communicate with the outpatient clinician responsible for follow‐up.
Provide and coordinate resources for patients to ensure safe transition from the hospital to arranged follow‐up care.
Utilize evidence based recommendations for the treatment of patients with asthma exacerbations.
SYSTEM ORGANIZATION AND IMPROVEMENT
To improve efficiency and quality within their organizations, Hospitalists should:
Develop educational modules, order sets, and/or pathways that facilitate use of evidence based strategies for asthma exacerbation in the emergency department and the hospital, with goals of improving outcomes, decreasing length of stay, and reducing re‐hospitalization rates.
Lead efforts to educate staff on the importance of smoking cessation counseling and other prevention measures.
Lead, coordinate or participate in multidisciplinary initiatives, which may include collaborative efforts with pulmonologists, to promote patient safety and optimize cost‐effective diagnostic and management strategies for patients with asthma.
Copyright © 2006 Society of Hospital Medicine
Acute renal failure
Acute renal failure (ARF) is defined as a decline in renal function over a period of hours or days, which results in an inability to maintain electrolyte homeostasis and an accumulation of nitrogenous waste products. ARF can be a presenting manifestation of a serious illness requiring hospitalization, or occur as a complication of illness or treatment in a hospitalized patient. the healthcare cost and utilization project (HCUP) estimates 141,000 discharges for ARF in 2002, with mean charges of almost $22,000 per patient. the mean length of stay was 6.7 days for these patients, with an in‐hospital mortality of 10.3%. hospitalists can advocate and initiate prevention strategies to reduce the incidence of ARF. hospitalists may also facilitate expeditious evaluation and management of ARF to improve patient outcomes, optimize resource utilization and reduce length of stay.
KNOWLEDGE
Hospitalists should be able to:
Define the clinical significance of pre‐renal failure, intrinsic renal disease, and post‐renal failure.
Describe the symptoms and signs of pre‐renal failure, intrinsic renal failure, and post‐renal failure.
Distinguish the causes of pre‐renal failure, intrinsic renal failure, and post‐renal failure.
Identify common electrolyte abnormalities that occur with acute renal failure, and institute corrective therapy.
Describe the indicated tests required to evaluate ARF.
Calculate estimated creatinine clearance for adjustment of medication dosage when indicated.
Identify patients at risk for ARF and institute preventive measures, which may include intravenous fluid and acetylcysteine in patients receiving radiocontrast media.
Identify hospitalized patients at risk for ARF and institute preventive measures.
Explain indications, contraindications and mechanisms of action of pharmacologic agents used to treat ARF.
Describe indications for acute hemodialysis.
Identify clinical, laboratory and imaging studies that indicate severity of disease.
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 for factors predisposing or contributing to the development of ARF.
Review all drug use including prescription and over‐the‐counter medications, herbal remedies, nutritional supplements, and illicit drugs.
Perform a physical examination to assess volume status and to identify underlying co‐morbid states that may result in ARF.
Order and interpret indicated diagnostic studies that may include urinalysis and microscopic sediment analysis, urinary diagnostic indices, urinary protein excretion, serologic evaluation, and renal imaging.
Avoid use of radiographic contrast agents and order non‐ionic agents when available.
Identify patients who may benefit from early hemodialysis.
Determine or coordinate appropriate nutritional and metabolic interventions.
Formulate a treatment plan tailored to the individual patient, which may include fluid management, pharmacologic agents and dosing, nutritional recommendations, and patient compliance.
Identify and treat factors that may complicate the management of ARF, including extremes of blood pressure and underlying infections.
Adjust medications according to estimated renal function and route of excretion.
Avoid use of nephrotoxic agents in ARF. if nephrotoxic agents are required, closely monitor drug levels and renal function.
Assess patients with suspected ARF in a timely manner, 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 ARF.
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.
Communicate with patients and families to explain tests and procedures and their indications, and to obtain informed consent.
Recognize indications for specialty consultation, which may include nephrology or urology.
Initiate prevention measures including dietary modification and renal dosing of medications.
Employ a multidisciplinary approach, which may include nursing, nutrition and pharmacy services in the care of patients with ARF that begins at admission and continues through all care transitions.
Document treatment plan and provide clear discharge instructions for post‐discharge physicians.
Facilitate discharge planning early during hospitalization, including providing the patient with contact information for follow‐up care.
Utilize evidence based recommendations and protocols and risk stratification tools for the treatment of ARF.
SYSTEM ORGANIZATION AND IMPROVEMENT
To improve efficiency and quality within their organizations, hospitalists should:
Advocate establishing and supporting initiatives that have been shown to reduce incidence of iatrogenic ARF.
Lead, coordinate or participate in multidisciplinary teams, which may include nephrology, nursing, pharmacy and nutrition services, to improve processes that facilitate early identification of ARF, early discharge planning, and improved patient outcomes.
Lead, coordinate or participate in multidisciplinary initiatives to promote patient safety and optimize management strategies for ARF.
Acute renal failure (ARF) is defined as a decline in renal function over a period of hours or days, which results in an inability to maintain electrolyte homeostasis and an accumulation of nitrogenous waste products. ARF can be a presenting manifestation of a serious illness requiring hospitalization, or occur as a complication of illness or treatment in a hospitalized patient. the healthcare cost and utilization project (HCUP) estimates 141,000 discharges for ARF in 2002, with mean charges of almost $22,000 per patient. the mean length of stay was 6.7 days for these patients, with an in‐hospital mortality of 10.3%. hospitalists can advocate and initiate prevention strategies to reduce the incidence of ARF. hospitalists may also facilitate expeditious evaluation and management of ARF to improve patient outcomes, optimize resource utilization and reduce length of stay.
KNOWLEDGE
Hospitalists should be able to:
Define the clinical significance of pre‐renal failure, intrinsic renal disease, and post‐renal failure.
Describe the symptoms and signs of pre‐renal failure, intrinsic renal failure, and post‐renal failure.
Distinguish the causes of pre‐renal failure, intrinsic renal failure, and post‐renal failure.
Identify common electrolyte abnormalities that occur with acute renal failure, and institute corrective therapy.
Describe the indicated tests required to evaluate ARF.
Calculate estimated creatinine clearance for adjustment of medication dosage when indicated.
Identify patients at risk for ARF and institute preventive measures, which may include intravenous fluid and acetylcysteine in patients receiving radiocontrast media.
Identify hospitalized patients at risk for ARF and institute preventive measures.
Explain indications, contraindications and mechanisms of action of pharmacologic agents used to treat ARF.
Describe indications for acute hemodialysis.
Identify clinical, laboratory and imaging studies that indicate severity of disease.
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 for factors predisposing or contributing to the development of ARF.
Review all drug use including prescription and over‐the‐counter medications, herbal remedies, nutritional supplements, and illicit drugs.
Perform a physical examination to assess volume status and to identify underlying co‐morbid states that may result in ARF.
Order and interpret indicated diagnostic studies that may include urinalysis and microscopic sediment analysis, urinary diagnostic indices, urinary protein excretion, serologic evaluation, and renal imaging.
Avoid use of radiographic contrast agents and order non‐ionic agents when available.
Identify patients who may benefit from early hemodialysis.
Determine or coordinate appropriate nutritional and metabolic interventions.
Formulate a treatment plan tailored to the individual patient, which may include fluid management, pharmacologic agents and dosing, nutritional recommendations, and patient compliance.
Identify and treat factors that may complicate the management of ARF, including extremes of blood pressure and underlying infections.
Adjust medications according to estimated renal function and route of excretion.
Avoid use of nephrotoxic agents in ARF. if nephrotoxic agents are required, closely monitor drug levels and renal function.
Assess patients with suspected ARF in a timely manner, 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 ARF.
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.
Communicate with patients and families to explain tests and procedures and their indications, and to obtain informed consent.
Recognize indications for specialty consultation, which may include nephrology or urology.
Initiate prevention measures including dietary modification and renal dosing of medications.
Employ a multidisciplinary approach, which may include nursing, nutrition and pharmacy services in the care of patients with ARF that begins at admission and continues through all care transitions.
Document treatment plan and provide clear discharge instructions for post‐discharge physicians.
Facilitate discharge planning early during hospitalization, including providing the patient with contact information for follow‐up care.
Utilize evidence based recommendations and protocols and risk stratification tools for the treatment of ARF.
SYSTEM ORGANIZATION AND IMPROVEMENT
To improve efficiency and quality within their organizations, hospitalists should:
Advocate establishing and supporting initiatives that have been shown to reduce incidence of iatrogenic ARF.
Lead, coordinate or participate in multidisciplinary teams, which may include nephrology, nursing, pharmacy and nutrition services, to improve processes that facilitate early identification of ARF, early discharge planning, and improved patient outcomes.
Lead, coordinate or participate in multidisciplinary initiatives to promote patient safety and optimize management strategies for ARF.
Acute renal failure (ARF) is defined as a decline in renal function over a period of hours or days, which results in an inability to maintain electrolyte homeostasis and an accumulation of nitrogenous waste products. ARF can be a presenting manifestation of a serious illness requiring hospitalization, or occur as a complication of illness or treatment in a hospitalized patient. the healthcare cost and utilization project (HCUP) estimates 141,000 discharges for ARF in 2002, with mean charges of almost $22,000 per patient. the mean length of stay was 6.7 days for these patients, with an in‐hospital mortality of 10.3%. hospitalists can advocate and initiate prevention strategies to reduce the incidence of ARF. hospitalists may also facilitate expeditious evaluation and management of ARF to improve patient outcomes, optimize resource utilization and reduce length of stay.
KNOWLEDGE
Hospitalists should be able to:
Define the clinical significance of pre‐renal failure, intrinsic renal disease, and post‐renal failure.
Describe the symptoms and signs of pre‐renal failure, intrinsic renal failure, and post‐renal failure.
Distinguish the causes of pre‐renal failure, intrinsic renal failure, and post‐renal failure.
Identify common electrolyte abnormalities that occur with acute renal failure, and institute corrective therapy.
Describe the indicated tests required to evaluate ARF.
Calculate estimated creatinine clearance for adjustment of medication dosage when indicated.
Identify patients at risk for ARF and institute preventive measures, which may include intravenous fluid and acetylcysteine in patients receiving radiocontrast media.
Identify hospitalized patients at risk for ARF and institute preventive measures.
Explain indications, contraindications and mechanisms of action of pharmacologic agents used to treat ARF.
Describe indications for acute hemodialysis.
Identify clinical, laboratory and imaging studies that indicate severity of disease.
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 for factors predisposing or contributing to the development of ARF.
Review all drug use including prescription and over‐the‐counter medications, herbal remedies, nutritional supplements, and illicit drugs.
Perform a physical examination to assess volume status and to identify underlying co‐morbid states that may result in ARF.
Order and interpret indicated diagnostic studies that may include urinalysis and microscopic sediment analysis, urinary diagnostic indices, urinary protein excretion, serologic evaluation, and renal imaging.
Avoid use of radiographic contrast agents and order non‐ionic agents when available.
Identify patients who may benefit from early hemodialysis.
Determine or coordinate appropriate nutritional and metabolic interventions.
Formulate a treatment plan tailored to the individual patient, which may include fluid management, pharmacologic agents and dosing, nutritional recommendations, and patient compliance.
Identify and treat factors that may complicate the management of ARF, including extremes of blood pressure and underlying infections.
Adjust medications according to estimated renal function and route of excretion.
Avoid use of nephrotoxic agents in ARF. if nephrotoxic agents are required, closely monitor drug levels and renal function.
Assess patients with suspected ARF in a timely manner, 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 ARF.
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.
Communicate with patients and families to explain tests and procedures and their indications, and to obtain informed consent.
Recognize indications for specialty consultation, which may include nephrology or urology.
Initiate prevention measures including dietary modification and renal dosing of medications.
Employ a multidisciplinary approach, which may include nursing, nutrition and pharmacy services in the care of patients with ARF that begins at admission and continues through all care transitions.
Document treatment plan and provide clear discharge instructions for post‐discharge physicians.
Facilitate discharge planning early during hospitalization, including providing the patient with contact information for follow‐up care.
Utilize evidence based recommendations and protocols and risk stratification tools for the treatment of ARF.
SYSTEM ORGANIZATION AND IMPROVEMENT
To improve efficiency and quality within their organizations, hospitalists should:
Advocate establishing and supporting initiatives that have been shown to reduce incidence of iatrogenic ARF.
Lead, coordinate or participate in multidisciplinary teams, which may include nephrology, nursing, pharmacy and nutrition services, to improve processes that facilitate early identification of ARF, early discharge planning, and improved patient outcomes.
Lead, coordinate or participate in multidisciplinary initiatives to promote patient safety and optimize management strategies for ARF.
Copyright © 2006 Society of Hospital Medicine
Hospitalist as consultant
Hospitalists may provide expert medical opinion regarding the care of hospitalized patients or may serve as consultants for patients under the care of other medical and surgical services. The hospitalist consultant may provide opinions and recommendations or actively manage the patient's hospital care. Effective and frequent communication between the hospitalist and the requesting physician ensures safe and quality care. Hospitalists should promote communication between services to improve the care of the hospitalized patient, optimize resource utilization, and enhance patient safety.
KNOWLEDGE
Hospitalists should be able to:
Define the role of the hospitalist consultant.
Describe the components of an effective consultation.
Assess the urgency of the consultation and the questions posed by the requesting physician.
List factors that may affect implementation of consultant's recommendations.
SKILLS
Hospitalists should be able to:
Obtain a thorough and relevant history and review the medical record.
Perform a relevant physical examination.
Interpret indicated diagnostic studies.
Synthesize a treatment plan based on the data obtained from the history, physical examination and diagnostic studies.
Summarize the findings in the patient record.
List concise but specific recommendations for management.
Communicate recommendations to the consulting physician in an expedient and efficient manner.
Assess the level of care required, and communicate with the requesting physician if a transition of care is advised.
ATTITUDES
Hospitalists should be able to:
Determine the hospitalist consultant's role in collaboration with the requesting physician.
Respond promptly to the requesting physician's need for consultation.
Lead by example by performing consultations in a collegial, professional and non‐confrontational manner.
Inform and educate the requesting physician of potential complications and opportunities for prevention of complications.
Provide frequent follow‐up, including review of pertinent findings and laboratory data, and ensure that critical recommendations have been followed.
Provide timely and effective communication with the requesting physician/team.
Transmit written communication legibly and with clear contact information.
Recognize when the hospitalist's role in the patient's care is complete, document final recommendations in the medical record, and maintain availability.
Communicate with patient and family to convey recommendations and treatment plans.
Recognize the importance of arranging appropriate follow‐up.
Lead, coordinate or participate in multidisciplinary initiatives to promote patient safety and optimize resource utilization.
Hospitalists may provide expert medical opinion regarding the care of hospitalized patients or may serve as consultants for patients under the care of other medical and surgical services. The hospitalist consultant may provide opinions and recommendations or actively manage the patient's hospital care. Effective and frequent communication between the hospitalist and the requesting physician ensures safe and quality care. Hospitalists should promote communication between services to improve the care of the hospitalized patient, optimize resource utilization, and enhance patient safety.
KNOWLEDGE
Hospitalists should be able to:
Define the role of the hospitalist consultant.
Describe the components of an effective consultation.
Assess the urgency of the consultation and the questions posed by the requesting physician.
List factors that may affect implementation of consultant's recommendations.
SKILLS
Hospitalists should be able to:
Obtain a thorough and relevant history and review the medical record.
Perform a relevant physical examination.
Interpret indicated diagnostic studies.
Synthesize a treatment plan based on the data obtained from the history, physical examination and diagnostic studies.
Summarize the findings in the patient record.
List concise but specific recommendations for management.
Communicate recommendations to the consulting physician in an expedient and efficient manner.
Assess the level of care required, and communicate with the requesting physician if a transition of care is advised.
ATTITUDES
Hospitalists should be able to:
Determine the hospitalist consultant's role in collaboration with the requesting physician.
Respond promptly to the requesting physician's need for consultation.
Lead by example by performing consultations in a collegial, professional and non‐confrontational manner.
Inform and educate the requesting physician of potential complications and opportunities for prevention of complications.
Provide frequent follow‐up, including review of pertinent findings and laboratory data, and ensure that critical recommendations have been followed.
Provide timely and effective communication with the requesting physician/team.
Transmit written communication legibly and with clear contact information.
Recognize when the hospitalist's role in the patient's care is complete, document final recommendations in the medical record, and maintain availability.
Communicate with patient and family to convey recommendations and treatment plans.
Recognize the importance of arranging appropriate follow‐up.
Lead, coordinate or participate in multidisciplinary initiatives to promote patient safety and optimize resource utilization.
Hospitalists may provide expert medical opinion regarding the care of hospitalized patients or may serve as consultants for patients under the care of other medical and surgical services. The hospitalist consultant may provide opinions and recommendations or actively manage the patient's hospital care. Effective and frequent communication between the hospitalist and the requesting physician ensures safe and quality care. Hospitalists should promote communication between services to improve the care of the hospitalized patient, optimize resource utilization, and enhance patient safety.
KNOWLEDGE
Hospitalists should be able to:
Define the role of the hospitalist consultant.
Describe the components of an effective consultation.
Assess the urgency of the consultation and the questions posed by the requesting physician.
List factors that may affect implementation of consultant's recommendations.
SKILLS
Hospitalists should be able to:
Obtain a thorough and relevant history and review the medical record.
Perform a relevant physical examination.
Interpret indicated diagnostic studies.
Synthesize a treatment plan based on the data obtained from the history, physical examination and diagnostic studies.
Summarize the findings in the patient record.
List concise but specific recommendations for management.
Communicate recommendations to the consulting physician in an expedient and efficient manner.
Assess the level of care required, and communicate with the requesting physician if a transition of care is advised.
ATTITUDES
Hospitalists should be able to:
Determine the hospitalist consultant's role in collaboration with the requesting physician.
Respond promptly to the requesting physician's need for consultation.
Lead by example by performing consultations in a collegial, professional and non‐confrontational manner.
Inform and educate the requesting physician of potential complications and opportunities for prevention of complications.
Provide frequent follow‐up, including review of pertinent findings and laboratory data, and ensure that critical recommendations have been followed.
Provide timely and effective communication with the requesting physician/team.
Transmit written communication legibly and with clear contact information.
Recognize when the hospitalist's role in the patient's care is complete, document final recommendations in the medical record, and maintain availability.
Communicate with patient and family to convey recommendations and treatment plans.
Recognize the importance of arranging appropriate follow‐up.
Lead, coordinate or participate in multidisciplinary initiatives to promote patient safety and optimize resource utilization.
Copyright © 2006 Society of Hospital Medicine