Identification of the core competencies of a medical specialty provides the necessary framework for that specialty to develop, refine itself, and evolve. It also provides a structure from which training, testing, and curricula can be developed and effectively utilized. For nearly a decade, since the coining of the term hospitalist,1 the field of hospital medicine has been emerging as the next generation of site‐defined specialties, after emergency medicine and critical care medicine. The Core Competencies in Hospital Medicine: A Framework for Curriculum Development (referred to as the Core Competencies from this point on) introduces the expectations of hospitalists, helps to define their role, and suggests how knowledge, skill, and attitude acquisition might be evaluated. Furthermore, this document provides an initial structural framework from which curricula in adult hospital medicine may be developed.

The Core Competencies document, produced by the Society of Hospital Medicine (SHM) and published as a supplement to the first issue of the Journal of Hospital Medicine,2 is meant to serve as a framework for educators at all levels of medical education to develop curricula, training, and evaluations for students, clinicians‐in‐training, and practicing hospitalists. The Core Competencies document is not meant to contain a complete compilation of inpatient clinical topics or to re‐create what many residency training programs in adult inpatient care already provide. It should not limit and does not define every aspect of hospitalist practice. It includes the most common and fundamental elements of inpatient care without exhaustively listing every clinical entity that may be encountered by a hospitalist. Some of the more common clinical topics encountered by inpatient physicians are included, with an emphasis on subject areas that stress a systems‐based approach to health care, which is central to the practice of hospital medicine. This initial version of the Core Competencies document also focuses on potential areas of deficiency in the training of physicians to become hospitalists. It provides developers of curricula and content with a standardized set of measurable learning objectives, while allowing them the flexibility needed to address specific contexts and incorporate advances in medicine.

The SHM, the sole professional organization representing inpatient physicians, defines hospitalists as physicians whose primary professional focus is the general medical care of hospitalized patients. Their activities include patient care, teaching, research, and leadership related to Hospital Medicine.3 An estimated 12,000 hospitalists are currently practicing in the United States, with a projected workforce need of an estimated 20,00030,000 practicing hospitalists in the United States in the next 510 years.4 Various factors have contributed to the rapid growth and expansion of hospital medicine, including factors related to care efficiency, care quality, and inpatient teaching.512 The pressures that have contributed to the development of and evolution toward the hospitalist model of care over the past decade are facilitating the transformation from a traditional model of inpatient care to the care of inpatients by hospitalist physicians dedicated primarily to the inpatient setting. As a result of this growth in hospital medicine, the SHM realized that core competencies were needed to help define the field.

The purpose of this article is to describe the developmental process and content structure of the Core Competencies document. It delineates the process from initial needs assessment to topic list development to chapter production to internal and external review and revisions of individual chapters and the complete document. The supplement to this first issue of the Journal of Hospital Medicine contains 1) the Core Competencies,2 2) a reprint of this article, and 3) a reprint of the article by McKean et al. in this issue detailing how to use the Core Competencies,13 with examples and suggestions related to curriculum development. The authors propose that this combined compilation may spur curriculum development in hospital medicine that will help to define the field and set expectations for practice.

PROCESS AND TIMELINE

Education Summit

Early in the growth of hospital medicine, the Society of Hospital Medicine identified a need to better define a common educational and practice framework for hospitalist physicians. Such a framework could help to define hospitalists as a distinct group of practicing physicians with common goals and a common set of competencies. The importance of identifying and delineating the common knowledge, skills, and attitudes of hospitalists was paramount. Figure 1 shows the details of the 4‐year process of developing the Core Competencies.

Figure 1

In 2002, the SHM drew together educational leaders in hospital medicine in its first educational summit. One of the primary charges that the SHM received from this summit was to develop the needed core curriculum in hospital medicine. After the summit, the SHM's Education Committee formed the Core Curriculum Task Force (CCTF), composed of approximately 15 member hospitalists, with representation from university and community hospitals, teaching and nonteaching programs, and for‐profit and not‐for‐profit settings from various geographic regions of the country. The selection process ensured that the task force was representative of practicing hospitalists and SHM membership throughout the United States.

CHAPTER CONTENT DESCRIPTION

As previously delineated, the Core Competencies document has three sections: Clinical Conditions, Procedures, and Healthcare Systems. The chapters in the entire compendium and within each section have been designed to stand alone and to be used either individually or collectively to assist with curriculum development in hospital medicine. However, each chapter should be used in the context of the entire document because a particular issue may only be touched on in one chapter but may be more elaborately detailed in another. For example, all clinical conditions chapters include a competency on the issue of care transitions, but the specific competencies for care transitions are presented in a separate Transitions of Care chapter.

All chapters in each section begin with an introduction that provides brief background information and establishes the relevance of the topic to practicing hospitalists. Each chapter then utilizes the educational theory of learning domains. The learning domains include the cognitive domain (knowledge), the psychomotor domain (skills), and the affective domain (attitudes). The companion article How to Use The Core Competencies in Hospital Medicine: A Framework for Curriculum Development13 describes in detail the educational theory guiding the development of the Core Competencies document and suggested methods for applying it to the development and revision of curricula and other training activities.

The task force further decided that each chapter in the Clinical Conditions and Procedures sections should include a subsection dedicated to system organization and improvement, an added domain that requires integration of knowledge, skills, and attitudes and the involvement of other medical services and disciplines for optimal patient care. The editorial board believed that system organization and improvement was already an intrinsic feature embedded in the chapters of the Healthcare Systems section. Therefore, this subsection was not included in those chapters.

Hospitalists subscribe to a systems organizational approach to clinical management and processes of care within the hospital. This systems approach, more than any level of knowledge or skill, is required to effectively and efficiently practice in the hospital setting. Practicing with a systems approach, with the interest of improving processes of care, is embedded throughout the Core Competencies document and is a practice method that all hospitalists may strive to achieve as they develop and improve their inpatient care. The competencies within the Systems Organization and Improvement section may contain a range of competency expectation (eg, lead, coordinate, or participate in) to acknowledge their uniqueness and variation according to practice settings and locally instituted responsibilities.

Each competency within a chapter details a level of proficiency, providing guidance on learning activities and potential evaluation strategies. Several overarching themes are followed in the chapters that help to define hospitalists as physicians who specialize in the care of hospitalized patients. First, hospitalists strive to support and adhere to a multidisciplinary approach for the patients under their care. Such an approach involves active interaction with and integration of other hospital medical staff (eg, nursing, rehabilitation therapies, social services) and of specialty medical or surgical services when indicated. Recognizing that hospitalists vary in experience and mastery of their field, the task force and editorial board believed that, at minimum, hospitalists would participate in multidisciplinary teams for improvement of the care and process related to the clinical conditions within their organization. However, they might also lead and/or coordinate teams in such efforts. Therefore, most chapters contain competencies that expect hospitalists to lead, coordinate, or participate in multidisciplinary teams or initiatives that will facilitate optimal care within their organization.

Second, because hospital medicine centers around the quality of inpatient care, participation in quality improvement (QI) initiatives, focusing on improving processes or systems of care in a local institution or organization, may be common in hospitalist practices. The level of involvement and role in QI initiatives may vary according to the particular system, the resources available, and a hospitalist's experience. Finally, because hospitalist care intrinsically involves an increase in the number of care transitions and handoffs, hospitalists need to remain sensitive to and focused on the care transitions that occur with their patients. Such transitions may occur as patients enter the hospital, move from one location to another within the hospital, or leave the hospital. This vulnerable time for patients requires hospitalists to be vigilant in their communication effortswith patients, with medical staff, and with outpatient clinicians.

Each competency was crafted to indicate the relevant concept, the level of proficiency expected, and a way to evaluate mastery. The teaching processes and learning experiences that must take place to achieve competency are left for curriculum developers and instructors to design. These core competencies represent an initial step in curriculum development, creating an identity and core set of expectations for hospitalists that we believe will lead to progress and maturity within the field.

SUMMARY AND FUTURE DIRECTIONS

The practice of hospital medicine requires proficiency of interrelated aspects of practiceclinical, procedural, and system‐based competencies. For practicing hospitalists, the Core Competencies document may serve as a resource to refine skills and assist in program development at individual institutions, both regionally and nationally. For residency program directors and clerkship directors, the Core Competencies document can function as a guide for developing the curriculum of inpatient medicine rotations or for meeting the requirements of the Outcomes Project of the Accreditation Council on Graduate Medical Education's. Last, for those developing continuing medical education programs, the Core Competencies document or individual chapters or topics within it may serve as an outline around which specific or broad‐based programs can be developed. Although the development of such curricula and the recipients of them should be evaluated, the actual evaluation is left to the curriculum developers.

Hospitalists are invested in making hospitals run better. They are positioned to take leadership roles in addressing quality, efficiency, and cost interests in both community and academic hospital settings. Their goals include improving care processes, hospital work life, and the setting in which they practice. The key core competencies described in this compendium define hospitalists as agents of change 1) to develop and implement systems to enable best practices to occur from admission through discharge, and 2) to promote the development of a safer culture within the hospital.

Hospital medicine remains an evolving specialty. Although great care was taken to construct these competencies so they would retain their relevance over time, SHM, the Core Curriculum Task Force, and the editorial board recognize the need for their continual reevaluation and modification in the context of advances and changes in the practice of hospital medicine. Our intent is that these competencies be a common reference and foundation for the creation of hospital medicine curricula and serve to standardize and improve training practices.

Identification of the core competencies of a medical specialty provides the necessary framework for that specialty to develop, refine itself, and evolve. It also provides a structure from which training, testing, and curricula can be developed and effectively utilized. For nearly a decade, since the coining of the term hospitalist,1 the field of hospital medicine has been emerging as the next generation of site‐defined specialties, after emergency medicine and critical care medicine. The Core Competencies in Hospital Medicine: A Framework for Curriculum Development (referred to as the Core Competencies from this point on) introduces the expectations of hospitalists, helps to define their role, and suggests how knowledge, skill, and attitude acquisition might be evaluated. Furthermore, this document provides an initial structural framework from which curricula in adult hospital medicine may be developed.

The Core Competencies document, produced by the Society of Hospital Medicine (SHM) and published as a supplement to the first issue of the Journal of Hospital Medicine,2 is meant to serve as a framework for educators at all levels of medical education to develop curricula, training, and evaluations for students, clinicians‐in‐training, and practicing hospitalists. The Core Competencies document is not meant to contain a complete compilation of inpatient clinical topics or to re‐create what many residency training programs in adult inpatient care already provide. It should not limit and does not define every aspect of hospitalist practice. It includes the most common and fundamental elements of inpatient care without exhaustively listing every clinical entity that may be encountered by a hospitalist. Some of the more common clinical topics encountered by inpatient physicians are included, with an emphasis on subject areas that stress a systems‐based approach to health care, which is central to the practice of hospital medicine. This initial version of the Core Competencies document also focuses on potential areas of deficiency in the training of physicians to become hospitalists. It provides developers of curricula and content with a standardized set of measurable learning objectives, while allowing them the flexibility needed to address specific contexts and incorporate advances in medicine.

The SHM, the sole professional organization representing inpatient physicians, defines hospitalists as physicians whose primary professional focus is the general medical care of hospitalized patients. Their activities include patient care, teaching, research, and leadership related to Hospital Medicine.3 An estimated 12,000 hospitalists are currently practicing in the United States, with a projected workforce need of an estimated 20,00030,000 practicing hospitalists in the United States in the next 510 years.4 Various factors have contributed to the rapid growth and expansion of hospital medicine, including factors related to care efficiency, care quality, and inpatient teaching.512 The pressures that have contributed to the development of and evolution toward the hospitalist model of care over the past decade are facilitating the transformation from a traditional model of inpatient care to the care of inpatients by hospitalist physicians dedicated primarily to the inpatient setting. As a result of this growth in hospital medicine, the SHM realized that core competencies were needed to help define the field.

The purpose of this article is to describe the developmental process and content structure of the Core Competencies document. It delineates the process from initial needs assessment to topic list development to chapter production to internal and external review and revisions of individual chapters and the complete document. The supplement to this first issue of the Journal of Hospital Medicine contains 1) the Core Competencies,2 2) a reprint of this article, and 3) a reprint of the article by McKean et al. in this issue detailing how to use the Core Competencies,13 with examples and suggestions related to curriculum development. The authors propose that this combined compilation may spur curriculum development in hospital medicine that will help to define the field and set expectations for practice.

PROCESS AND TIMELINE

Education Summit

Early in the growth of hospital medicine, the Society of Hospital Medicine identified a need to better define a common educational and practice framework for hospitalist physicians. Such a framework could help to define hospitalists as a distinct group of practicing physicians with common goals and a common set of competencies. The importance of identifying and delineating the common knowledge, skills, and attitudes of hospitalists was paramount. Figure 1 shows the details of the 4‐year process of developing the Core Competencies.

Figure 1

In 2002, the SHM drew together educational leaders in hospital medicine in its first educational summit. One of the primary charges that the SHM received from this summit was to develop the needed core curriculum in hospital medicine. After the summit, the SHM's Education Committee formed the Core Curriculum Task Force (CCTF), composed of approximately 15 member hospitalists, with representation from university and community hospitals, teaching and nonteaching programs, and for‐profit and not‐for‐profit settings from various geographic regions of the country. The selection process ensured that the task force was representative of practicing hospitalists and SHM membership throughout the United States.

CHAPTER CONTENT DESCRIPTION

As previously delineated, the Core Competencies document has three sections: Clinical Conditions, Procedures, and Healthcare Systems. The chapters in the entire compendium and within each section have been designed to stand alone and to be used either individually or collectively to assist with curriculum development in hospital medicine. However, each chapter should be used in the context of the entire document because a particular issue may only be touched on in one chapter but may be more elaborately detailed in another. For example, all clinical conditions chapters include a competency on the issue of care transitions, but the specific competencies for care transitions are presented in a separate Transitions of Care chapter.

All chapters in each section begin with an introduction that provides brief background information and establishes the relevance of the topic to practicing hospitalists. Each chapter then utilizes the educational theory of learning domains. The learning domains include the cognitive domain (knowledge), the psychomotor domain (skills), and the affective domain (attitudes). The companion article How to Use The Core Competencies in Hospital Medicine: A Framework for Curriculum Development13 describes in detail the educational theory guiding the development of the Core Competencies document and suggested methods for applying it to the development and revision of curricula and other training activities.

The task force further decided that each chapter in the Clinical Conditions and Procedures sections should include a subsection dedicated to system organization and improvement, an added domain that requires integration of knowledge, skills, and attitudes and the involvement of other medical services and disciplines for optimal patient care. The editorial board believed that system organization and improvement was already an intrinsic feature embedded in the chapters of the Healthcare Systems section. Therefore, this subsection was not included in those chapters.

Hospitalists subscribe to a systems organizational approach to clinical management and processes of care within the hospital. This systems approach, more than any level of knowledge or skill, is required to effectively and efficiently practice in the hospital setting. Practicing with a systems approach, with the interest of improving processes of care, is embedded throughout the Core Competencies document and is a practice method that all hospitalists may strive to achieve as they develop and improve their inpatient care. The competencies within the Systems Organization and Improvement section may contain a range of competency expectation (eg, lead, coordinate, or participate in) to acknowledge their uniqueness and variation according to practice settings and locally instituted responsibilities.

Each competency within a chapter details a level of proficiency, providing guidance on learning activities and potential evaluation strategies. Several overarching themes are followed in the chapters that help to define hospitalists as physicians who specialize in the care of hospitalized patients. First, hospitalists strive to support and adhere to a multidisciplinary approach for the patients under their care. Such an approach involves active interaction with and integration of other hospital medical staff (eg, nursing, rehabilitation therapies, social services) and of specialty medical or surgical services when indicated. Recognizing that hospitalists vary in experience and mastery of their field, the task force and editorial board believed that, at minimum, hospitalists would participate in multidisciplinary teams for improvement of the care and process related to the clinical conditions within their organization. However, they might also lead and/or coordinate teams in such efforts. Therefore, most chapters contain competencies that expect hospitalists to lead, coordinate, or participate in multidisciplinary teams or initiatives that will facilitate optimal care within their organization.

Second, because hospital medicine centers around the quality of inpatient care, participation in quality improvement (QI) initiatives, focusing on improving processes or systems of care in a local institution or organization, may be common in hospitalist practices. The level of involvement and role in QI initiatives may vary according to the particular system, the resources available, and a hospitalist's experience. Finally, because hospitalist care intrinsically involves an increase in the number of care transitions and handoffs, hospitalists need to remain sensitive to and focused on the care transitions that occur with their patients. Such transitions may occur as patients enter the hospital, move from one location to another within the hospital, or leave the hospital. This vulnerable time for patients requires hospitalists to be vigilant in their communication effortswith patients, with medical staff, and with outpatient clinicians.

Each competency was crafted to indicate the relevant concept, the level of proficiency expected, and a way to evaluate mastery. The teaching processes and learning experiences that must take place to achieve competency are left for curriculum developers and instructors to design. These core competencies represent an initial step in curriculum development, creating an identity and core set of expectations for hospitalists that we believe will lead to progress and maturity within the field.

SUMMARY AND FUTURE DIRECTIONS

The practice of hospital medicine requires proficiency of interrelated aspects of practiceclinical, procedural, and system‐based competencies. For practicing hospitalists, the Core Competencies document may serve as a resource to refine skills and assist in program development at individual institutions, both regionally and nationally. For residency program directors and clerkship directors, the Core Competencies document can function as a guide for developing the curriculum of inpatient medicine rotations or for meeting the requirements of the Outcomes Project of the Accreditation Council on Graduate Medical Education's. Last, for those developing continuing medical education programs, the Core Competencies document or individual chapters or topics within it may serve as an outline around which specific or broad‐based programs can be developed. Although the development of such curricula and the recipients of them should be evaluated, the actual evaluation is left to the curriculum developers.

Hospitalists are invested in making hospitals run better. They are positioned to take leadership roles in addressing quality, efficiency, and cost interests in both community and academic hospital settings. Their goals include improving care processes, hospital work life, and the setting in which they practice. The key core competencies described in this compendium define hospitalists as agents of change 1) to develop and implement systems to enable best practices to occur from admission through discharge, and 2) to promote the development of a safer culture within the hospital.

Hospital medicine remains an evolving specialty. Although great care was taken to construct these competencies so they would retain their relevance over time, SHM, the Core Curriculum Task Force, and the editorial board recognize the need for their continual reevaluation and modification in the context of advances and changes in the practice of hospital medicine. Our intent is that these competencies be a common reference and foundation for the creation of hospital medicine curricula and serve to standardize and improve training practices.

Identification of the core competencies of a medical specialty provides the necessary framework for that specialty to develop, refine itself, and evolve. It also provides a structure from which training, testing, and curricula can be developed and effectively utilized. For nearly a decade, since the coining of the term hospitalist,1 the field of hospital medicine has been emerging as the next generation of site‐defined specialties, after emergency medicine and critical care medicine. The Core Competencies in Hospital Medicine: A Framework for Curriculum Development (referred to as the Core Competencies from this point on) introduces the expectations of hospitalists, helps to define their role, and suggests how knowledge, skill, and attitude acquisition might be evaluated. Furthermore, this document provides an initial structural framework from which curricula in adult hospital medicine may be developed.

The Core Competencies document, produced by the Society of Hospital Medicine (SHM) and published as a supplement to the first issue of the Journal of Hospital Medicine,2 is meant to serve as a framework for educators at all levels of medical education to develop curricula, training, and evaluations for students, clinicians‐in‐training, and practicing hospitalists. The Core Competencies document is not meant to contain a complete compilation of inpatient clinical topics or to re‐create what many residency training programs in adult inpatient care already provide. It should not limit and does not define every aspect of hospitalist practice. It includes the most common and fundamental elements of inpatient care without exhaustively listing every clinical entity that may be encountered by a hospitalist. Some of the more common clinical topics encountered by inpatient physicians are included, with an emphasis on subject areas that stress a systems‐based approach to health care, which is central to the practice of hospital medicine. This initial version of the Core Competencies document also focuses on potential areas of deficiency in the training of physicians to become hospitalists. It provides developers of curricula and content with a standardized set of measurable learning objectives, while allowing them the flexibility needed to address specific contexts and incorporate advances in medicine.

The SHM, the sole professional organization representing inpatient physicians, defines hospitalists as physicians whose primary professional focus is the general medical care of hospitalized patients. Their activities include patient care, teaching, research, and leadership related to Hospital Medicine.3 An estimated 12,000 hospitalists are currently practicing in the United States, with a projected workforce need of an estimated 20,00030,000 practicing hospitalists in the United States in the next 510 years.4 Various factors have contributed to the rapid growth and expansion of hospital medicine, including factors related to care efficiency, care quality, and inpatient teaching.512 The pressures that have contributed to the development of and evolution toward the hospitalist model of care over the past decade are facilitating the transformation from a traditional model of inpatient care to the care of inpatients by hospitalist physicians dedicated primarily to the inpatient setting. As a result of this growth in hospital medicine, the SHM realized that core competencies were needed to help define the field.

The purpose of this article is to describe the developmental process and content structure of the Core Competencies document. It delineates the process from initial needs assessment to topic list development to chapter production to internal and external review and revisions of individual chapters and the complete document. The supplement to this first issue of the Journal of Hospital Medicine contains 1) the Core Competencies,2 2) a reprint of this article, and 3) a reprint of the article by McKean et al. in this issue detailing how to use the Core Competencies,13 with examples and suggestions related to curriculum development. The authors propose that this combined compilation may spur curriculum development in hospital medicine that will help to define the field and set expectations for practice.

PROCESS AND TIMELINE

Education Summit

Early in the growth of hospital medicine, the Society of Hospital Medicine identified a need to better define a common educational and practice framework for hospitalist physicians. Such a framework could help to define hospitalists as a distinct group of practicing physicians with common goals and a common set of competencies. The importance of identifying and delineating the common knowledge, skills, and attitudes of hospitalists was paramount. Figure 1 shows the details of the 4‐year process of developing the Core Competencies.

Figure 1

In 2002, the SHM drew together educational leaders in hospital medicine in its first educational summit. One of the primary charges that the SHM received from this summit was to develop the needed core curriculum in hospital medicine. After the summit, the SHM's Education Committee formed the Core Curriculum Task Force (CCTF), composed of approximately 15 member hospitalists, with representation from university and community hospitals, teaching and nonteaching programs, and for‐profit and not‐for‐profit settings from various geographic regions of the country. The selection process ensured that the task force was representative of practicing hospitalists and SHM membership throughout the United States.

CHAPTER CONTENT DESCRIPTION

As previously delineated, the Core Competencies document has three sections: Clinical Conditions, Procedures, and Healthcare Systems. The chapters in the entire compendium and within each section have been designed to stand alone and to be used either individually or collectively to assist with curriculum development in hospital medicine. However, each chapter should be used in the context of the entire document because a particular issue may only be touched on in one chapter but may be more elaborately detailed in another. For example, all clinical conditions chapters include a competency on the issue of care transitions, but the specific competencies for care transitions are presented in a separate Transitions of Care chapter.

All chapters in each section begin with an introduction that provides brief background information and establishes the relevance of the topic to practicing hospitalists. Each chapter then utilizes the educational theory of learning domains. The learning domains include the cognitive domain (knowledge), the psychomotor domain (skills), and the affective domain (attitudes). The companion article How to Use The Core Competencies in Hospital Medicine: A Framework for Curriculum Development13 describes in detail the educational theory guiding the development of the Core Competencies document and suggested methods for applying it to the development and revision of curricula and other training activities.

The task force further decided that each chapter in the Clinical Conditions and Procedures sections should include a subsection dedicated to system organization and improvement, an added domain that requires integration of knowledge, skills, and attitudes and the involvement of other medical services and disciplines for optimal patient care. The editorial board believed that system organization and improvement was already an intrinsic feature embedded in the chapters of the Healthcare Systems section. Therefore, this subsection was not included in those chapters.

Hospitalists subscribe to a systems organizational approach to clinical management and processes of care within the hospital. This systems approach, more than any level of knowledge or skill, is required to effectively and efficiently practice in the hospital setting. Practicing with a systems approach, with the interest of improving processes of care, is embedded throughout the Core Competencies document and is a practice method that all hospitalists may strive to achieve as they develop and improve their inpatient care. The competencies within the Systems Organization and Improvement section may contain a range of competency expectation (eg, lead, coordinate, or participate in) to acknowledge their uniqueness and variation according to practice settings and locally instituted responsibilities.

Each competency within a chapter details a level of proficiency, providing guidance on learning activities and potential evaluation strategies. Several overarching themes are followed in the chapters that help to define hospitalists as physicians who specialize in the care of hospitalized patients. First, hospitalists strive to support and adhere to a multidisciplinary approach for the patients under their care. Such an approach involves active interaction with and integration of other hospital medical staff (eg, nursing, rehabilitation therapies, social services) and of specialty medical or surgical services when indicated. Recognizing that hospitalists vary in experience and mastery of their field, the task force and editorial board believed that, at minimum, hospitalists would participate in multidisciplinary teams for improvement of the care and process related to the clinical conditions within their organization. However, they might also lead and/or coordinate teams in such efforts. Therefore, most chapters contain competencies that expect hospitalists to lead, coordinate, or participate in multidisciplinary teams or initiatives that will facilitate optimal care within their organization.

Second, because hospital medicine centers around the quality of inpatient care, participation in quality improvement (QI) initiatives, focusing on improving processes or systems of care in a local institution or organization, may be common in hospitalist practices. The level of involvement and role in QI initiatives may vary according to the particular system, the resources available, and a hospitalist's experience. Finally, because hospitalist care intrinsically involves an increase in the number of care transitions and handoffs, hospitalists need to remain sensitive to and focused on the care transitions that occur with their patients. Such transitions may occur as patients enter the hospital, move from one location to another within the hospital, or leave the hospital. This vulnerable time for patients requires hospitalists to be vigilant in their communication effortswith patients, with medical staff, and with outpatient clinicians.

Each competency was crafted to indicate the relevant concept, the level of proficiency expected, and a way to evaluate mastery. The teaching processes and learning experiences that must take place to achieve competency are left for curriculum developers and instructors to design. These core competencies represent an initial step in curriculum development, creating an identity and core set of expectations for hospitalists that we believe will lead to progress and maturity within the field.

SUMMARY AND FUTURE DIRECTIONS

The practice of hospital medicine requires proficiency of interrelated aspects of practiceclinical, procedural, and system‐based competencies. For practicing hospitalists, the Core Competencies document may serve as a resource to refine skills and assist in program development at individual institutions, both regionally and nationally. For residency program directors and clerkship directors, the Core Competencies document can function as a guide for developing the curriculum of inpatient medicine rotations or for meeting the requirements of the Outcomes Project of the Accreditation Council on Graduate Medical Education's. Last, for those developing continuing medical education programs, the Core Competencies document or individual chapters or topics within it may serve as an outline around which specific or broad‐based programs can be developed. Although the development of such curricula and the recipients of them should be evaluated, the actual evaluation is left to the curriculum developers.

Hospitalists are invested in making hospitals run better. They are positioned to take leadership roles in addressing quality, efficiency, and cost interests in both community and academic hospital settings. Their goals include improving care processes, hospital work life, and the setting in which they practice. The key core competencies described in this compendium define hospitalists as agents of change 1) to develop and implement systems to enable best practices to occur from admission through discharge, and 2) to promote the development of a safer culture within the hospital.

Hospital medicine remains an evolving specialty. Although great care was taken to construct these competencies so they would retain their relevance over time, SHM, the Core Curriculum Task Force, and the editorial board recognize the need for their continual reevaluation and modification in the context of advances and changes in the practice of hospital medicine. Our intent is that these competencies be a common reference and foundation for the creation of hospital medicine curricula and serve to standardize and improve training practices.

Cellulitis is a bacterial infection of the skin and subcutaneous tissues. the healthcare cost and utilization project (hcup) states there were approximately 340,000 hospital discharges in 2002 with a diagnosis related group (drg) for cellulitis. patients with cellulitis with complications and co‐morbidities had a mean length‐of‐stay of 5.3 days with an in‐hospital mortality of 0.8%. the mean charges for these patients were $13,000. the figures were slightly improved for uncomplicated cellulitis, as the mean length‐of‐stay dropped to 3.6 days and total charges decreased to $8,000 per patient. hospitalists can provide leadership to standardize care delivery, improve discharge planning, and promptly identify and address severe cases of cellulitis that require further intervention.

KNOWLEDGE

Hospitalists should be able to:

• Describe the clinical presentation of cellulitis and compare routine and complicated cellulitis.

• Differentiate cellulitis from chronic venous stasis and other conditions that may mimic cellulitis and discuss the accuracy of signs/symptoms in patients admitted with cellulitis.

• Describe the indicated tests required to evaluate cellulitis.

• Relate cellulitis with certain host exposures (including pseudomonas with hot tub exposure, streptococci and venous harvest site cellulitis, and aeromonas with fresh or brackish water).

• Identify patients with co‐morbidities (such as the immunocompromised patient, and those with chronic venous and lymphatic problems) and extremes of age (the elderly and the very young) who are at increased risk for a complicated course of cellulitis.

• Differentiate empiric antibiotic regimens for uncomplicated and complicated types of cellulitis.

• Explain indications for inpatient admission.

• Describe the prognostic indicators, including patient co‐morbidities, for complicated and uncomplicated cellulitis.

• 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 precipitating causes of cellulitis and co‐morbid conditions that may impact clinical management.

• Accurately identify and document cellulitis borders and signs of complications, which may include crepitis and abscess.

• Determine and interpret an appropriate and cost‐effective initial diagnostic evaluation of cellulitis including laboratory and radiological studies.

• Initiate empiric antibiotic treatment of cellulitis based on host exposures, predisposing underlying systemic illness, history and physical examination, presumptive bacterial pathogens, and evidence based recommendations.

• Treat co‐existing fungal infection, edema, and other conditions that may exacerbate cellulitis.

• Formulate a subsequent treatment plan that includes narrowing antibiotic therapies based on available culture data and patient response to treatment.

• Determine appropriate timing for transition from intravenous to oral therapy.

• Assess patients with cellulitis 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 cellulitis.

• 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 their indications, and obtain informed consent.

• Recognize the need for early specialty consultation in cases with complications, misdiagnosis, or lack of response to therapy.

• Initiate prevention measures for recurrent cellulites, prior to discharge.

• Employ a multidisciplinary approach to the care of patients with cellulitis that begins at admission and continues through discharge.

• Communicate to outpatient providers the notable events of the hospitalization and anticipated post‐discharge needs.

• Consider cost effectiveness (including formulary availability), and ease of conversion to outpatient treatment when choosing among therapeutic options.

• Employ multidisciplinary teams to facilitate discharge planning.

• Utilize evidence based recommendations to guide diagnosis, monitoring and treatment of cellulitis.

SYSTEM ORGANIZATIONS AND IMPROVEMENT

To improve efficiency and quality within their organizations, hospitalists should:

• Implement systems to ensure hospital‐wide adherence to national standards, and document those measures as specified by recognized organizations.

• Lead, coordinate or participate in multidisciplinary initiatives, which may include collaboration with infectious disease physicians, to promote patient safety and optimize cost‐effective diagnostic and management strategies for patients with cellulitis.

Cellulitis is a bacterial infection of the skin and subcutaneous tissues. the healthcare cost and utilization project (hcup) states there were approximately 340,000 hospital discharges in 2002 with a diagnosis related group (drg) for cellulitis. patients with cellulitis with complications and co‐morbidities had a mean length‐of‐stay of 5.3 days with an in‐hospital mortality of 0.8%. the mean charges for these patients were $13,000. the figures were slightly improved for uncomplicated cellulitis, as the mean length‐of‐stay dropped to 3.6 days and total charges decreased to $8,000 per patient. hospitalists can provide leadership to standardize care delivery, improve discharge planning, and promptly identify and address severe cases of cellulitis that require further intervention.

KNOWLEDGE

Hospitalists should be able to:

• Describe the clinical presentation of cellulitis and compare routine and complicated cellulitis.

• Differentiate cellulitis from chronic venous stasis and other conditions that may mimic cellulitis and discuss the accuracy of signs/symptoms in patients admitted with cellulitis.

• Describe the indicated tests required to evaluate cellulitis.

• Relate cellulitis with certain host exposures (including pseudomonas with hot tub exposure, streptococci and venous harvest site cellulitis, and aeromonas with fresh or brackish water).

• Identify patients with co‐morbidities (such as the immunocompromised patient, and those with chronic venous and lymphatic problems) and extremes of age (the elderly and the very young) who are at increased risk for a complicated course of cellulitis.

• Differentiate empiric antibiotic regimens for uncomplicated and complicated types of cellulitis.

• Explain indications for inpatient admission.

• Describe the prognostic indicators, including patient co‐morbidities, for complicated and uncomplicated cellulitis.

• 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 precipitating causes of cellulitis and co‐morbid conditions that may impact clinical management.

• Accurately identify and document cellulitis borders and signs of complications, which may include crepitis and abscess.

• Determine and interpret an appropriate and cost‐effective initial diagnostic evaluation of cellulitis including laboratory and radiological studies.

• Initiate empiric antibiotic treatment of cellulitis based on host exposures, predisposing underlying systemic illness, history and physical examination, presumptive bacterial pathogens, and evidence based recommendations.

• Treat co‐existing fungal infection, edema, and other conditions that may exacerbate cellulitis.

• Formulate a subsequent treatment plan that includes narrowing antibiotic therapies based on available culture data and patient response to treatment.

• Determine appropriate timing for transition from intravenous to oral therapy.

• Assess patients with cellulitis 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 cellulitis.

• 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 their indications, and obtain informed consent.

• Recognize the need for early specialty consultation in cases with complications, misdiagnosis, or lack of response to therapy.

• Initiate prevention measures for recurrent cellulites, prior to discharge.

• Employ a multidisciplinary approach to the care of patients with cellulitis that begins at admission and continues through discharge.

• Communicate to outpatient providers the notable events of the hospitalization and anticipated post‐discharge needs.

• Consider cost effectiveness (including formulary availability), and ease of conversion to outpatient treatment when choosing among therapeutic options.

• Employ multidisciplinary teams to facilitate discharge planning.

• Utilize evidence based recommendations to guide diagnosis, monitoring and treatment of cellulitis.

SYSTEM ORGANIZATIONS AND IMPROVEMENT

To improve efficiency and quality within their organizations, hospitalists should:

• Implement systems to ensure hospital‐wide adherence to national standards, and document those measures as specified by recognized organizations.

• Lead, coordinate or participate in multidisciplinary initiatives, which may include collaboration with infectious disease physicians, to promote patient safety and optimize cost‐effective diagnostic and management strategies for patients with cellulitis.

Cellulitis is a bacterial infection of the skin and subcutaneous tissues. the healthcare cost and utilization project (hcup) states there were approximately 340,000 hospital discharges in 2002 with a diagnosis related group (drg) for cellulitis. patients with cellulitis with complications and co‐morbidities had a mean length‐of‐stay of 5.3 days with an in‐hospital mortality of 0.8%. the mean charges for these patients were $13,000. the figures were slightly improved for uncomplicated cellulitis, as the mean length‐of‐stay dropped to 3.6 days and total charges decreased to $8,000 per patient. hospitalists can provide leadership to standardize care delivery, improve discharge planning, and promptly identify and address severe cases of cellulitis that require further intervention.

KNOWLEDGE

Hospitalists should be able to:

• Describe the clinical presentation of cellulitis and compare routine and complicated cellulitis.

• Differentiate cellulitis from chronic venous stasis and other conditions that may mimic cellulitis and discuss the accuracy of signs/symptoms in patients admitted with cellulitis.

• Describe the indicated tests required to evaluate cellulitis.

• Relate cellulitis with certain host exposures (including pseudomonas with hot tub exposure, streptococci and venous harvest site cellulitis, and aeromonas with fresh or brackish water).

• Identify patients with co‐morbidities (such as the immunocompromised patient, and those with chronic venous and lymphatic problems) and extremes of age (the elderly and the very young) who are at increased risk for a complicated course of cellulitis.

• Differentiate empiric antibiotic regimens for uncomplicated and complicated types of cellulitis.

• Explain indications for inpatient admission.

• Describe the prognostic indicators, including patient co‐morbidities, for complicated and uncomplicated cellulitis.

• 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 precipitating causes of cellulitis and co‐morbid conditions that may impact clinical management.

• Accurately identify and document cellulitis borders and signs of complications, which may include crepitis and abscess.

• Determine and interpret an appropriate and cost‐effective initial diagnostic evaluation of cellulitis including laboratory and radiological studies.

• Initiate empiric antibiotic treatment of cellulitis based on host exposures, predisposing underlying systemic illness, history and physical examination, presumptive bacterial pathogens, and evidence based recommendations.

• Treat co‐existing fungal infection, edema, and other conditions that may exacerbate cellulitis.

• Formulate a subsequent treatment plan that includes narrowing antibiotic therapies based on available culture data and patient response to treatment.

• Determine appropriate timing for transition from intravenous to oral therapy.

• Assess patients with cellulitis 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 cellulitis.

• 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 their indications, and obtain informed consent.

• Recognize the need for early specialty consultation in cases with complications, misdiagnosis, or lack of response to therapy.

• Initiate prevention measures for recurrent cellulites, prior to discharge.

• Employ a multidisciplinary approach to the care of patients with cellulitis that begins at admission and continues through discharge.

• Communicate to outpatient providers the notable events of the hospitalization and anticipated post‐discharge needs.

• Consider cost effectiveness (including formulary availability), and ease of conversion to outpatient treatment when choosing among therapeutic options.

• Employ multidisciplinary teams to facilitate discharge planning.

• Utilize evidence based recommendations to guide diagnosis, monitoring and treatment of cellulitis.

SYSTEM ORGANIZATIONS AND IMPROVEMENT

To improve efficiency and quality within their organizations, hospitalists should:

• Implement systems to ensure hospital‐wide adherence to national standards, and document those measures as specified by recognized organizations.

• Lead, coordinate or participate in multidisciplinary initiatives, which may include collaboration with infectious disease physicians, to promote patient safety and optimize cost‐effective diagnostic and management strategies for patients with cellulitis.

Hospital‐acquired pneumonia (HAP) is an infection of the lung parenchyma that occurs during the course of hospitalization. HAP is a significant source of morbidity, mortality, and increased resource expenditures. The attributable mortality for hap is in the 3050 percent range. The primary risk factor for the development of HAP is mechanical ventilation. The average length of stay for patients with HAP increases by an average of 13 days, with estimated additional costs of $40,000. Hospitalists manage patients with HAP either as an attending physician or as a consultant to patients admitted to other services. Hospitalists can initiate quality improvement strategies at the individual patient level and at the system level to improve patient outcomes and optimize resource utilization.

KNOWLEDGE

Hospitalists should be able to:

• Define hospital‐acquired pneumonia (HAP).

• List common organisms associated with HAP.

• Describe local and national resistance patterns for HAP.

• Identify important historical elements, medical record data and physical examination findings consistent with HAP.

• Distinguish the infectious causes of HAP.

• Describe the indicated tests required to evaluate HAP.

• Identify patients at risk for developing HAP.

• Describe the role of mechanical ventilation as a risk factor for the development of HAP.

• Explain the prophylactic measures commonly used to lower the risk of HAP.

• Describe the role of mechanical ventilation as a potential treatment option for HAP.

• Describe infection control practices to prevent the spread of resistant organisms within the hospital.

• Describe potential complications of HAP.

• 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 perform a targeted physical examination for hospital‐acquired pneumonia.

• Order and interpret indicated laboratory, microbiologic and radiological studies to confirm diagnosis of hospital acquired pneumonia and determine the etiologic agent.

• Initiate empiric antibiotic regimen based on patient history and underlying co‐morbid conditions, likely organisms and local resistance patterns.

• Tailor antibiotic regimens based on microbiologic culture and sensitivity data as soon as available.

• Manage complications, which may include respiratory failure, pleural effusions and empyema.

• Coordinate care for patients requiring mechanical ventilation.

• Identify patients who require thoracentesis, perform or coordinate the procedure, and interpret the results.

• Assess patients with suspected hospital‐acquired pneumonia 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 etiology, management plan, and potential outcomes of hospital‐acquired pneumonia.

• Communicate with patients and families to explain the tests and procedures and their indications, and to obtain informed consent.

• Recognize indications for specialty consultation, which may include infectious disease and/or pulmonary services.

• Employ a multidisciplinary approach, which may include nursing, respiratory therapy, nutrition and pharmacy services, to the care of patients with HAP through all care transitions.

• Recognize steps that can be employed to limit the emergence of antibiotic resistance.

• Document treatment plan and provide clear discharge instructions for post‐discharge physicians.

• Recognize implications of HAP on discharge planning.

• Lead multidisciplinary teams to facilitate discharge planning, and communicate to outpatient providers the notable events of the hospitalization and anticipated post‐discharge needs.

• Utilize evidence based recommendations and protocols and risk stratification tools for the treatment of HAP.

SYSTEM ORGANIZATION AND IMPROVEMENT

To improve efficiency and quality within their organizations, Hospitalists should:

• Collaborate with local infection control practitioners to reduce the spread of resistant organisms within the institution.

• Lead, coordinate or participate in multidisciplinary initiatives, which may include collaboration with critical care specialists and pulmonologists, to reduce the incidence of hospital‐acquired pneumonia in ventilated patients.

• Lead, coordinate or participate in quality improvement initiatives to reduce ventilator days, rates of HAP, and variance in antibiotic use.

• Implement systems to ensure hospital‐wide adherence to national standards for empiric antibiotic use, and document those measures as specified by recognized organizations.

• Lead efforts to educate staff on the importance of smoking cessation counseling and other prevention measures.

Hospital‐acquired pneumonia (HAP) is an infection of the lung parenchyma that occurs during the course of hospitalization. HAP is a significant source of morbidity, mortality, and increased resource expenditures. The attributable mortality for hap is in the 3050 percent range. The primary risk factor for the development of HAP is mechanical ventilation. The average length of stay for patients with HAP increases by an average of 13 days, with estimated additional costs of $40,000. Hospitalists manage patients with HAP either as an attending physician or as a consultant to patients admitted to other services. Hospitalists can initiate quality improvement strategies at the individual patient level and at the system level to improve patient outcomes and optimize resource utilization.

KNOWLEDGE

Hospitalists should be able to:

• Define hospital‐acquired pneumonia (HAP).

• List common organisms associated with HAP.

• Describe local and national resistance patterns for HAP.

• Identify important historical elements, medical record data and physical examination findings consistent with HAP.

• Distinguish the infectious causes of HAP.

• Describe the indicated tests required to evaluate HAP.

• Identify patients at risk for developing HAP.

• Describe the role of mechanical ventilation as a risk factor for the development of HAP.

• Explain the prophylactic measures commonly used to lower the risk of HAP.

• Describe the role of mechanical ventilation as a potential treatment option for HAP.

• Describe infection control practices to prevent the spread of resistant organisms within the hospital.

• Describe potential complications of HAP.

• 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 perform a targeted physical examination for hospital‐acquired pneumonia.

• Order and interpret indicated laboratory, microbiologic and radiological studies to confirm diagnosis of hospital acquired pneumonia and determine the etiologic agent.

• Initiate empiric antibiotic regimen based on patient history and underlying co‐morbid conditions, likely organisms and local resistance patterns.

• Tailor antibiotic regimens based on microbiologic culture and sensitivity data as soon as available.

• Manage complications, which may include respiratory failure, pleural effusions and empyema.

• Coordinate care for patients requiring mechanical ventilation.

• Identify patients who require thoracentesis, perform or coordinate the procedure, and interpret the results.

• Assess patients with suspected hospital‐acquired pneumonia 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 etiology, management plan, and potential outcomes of hospital‐acquired pneumonia.

• Communicate with patients and families to explain the tests and procedures and their indications, and to obtain informed consent.

• Recognize indications for specialty consultation, which may include infectious disease and/or pulmonary services.

• Employ a multidisciplinary approach, which may include nursing, respiratory therapy, nutrition and pharmacy services, to the care of patients with HAP through all care transitions.

• Recognize steps that can be employed to limit the emergence of antibiotic resistance.

• Document treatment plan and provide clear discharge instructions for post‐discharge physicians.

• Recognize implications of HAP on discharge planning.

• Lead multidisciplinary teams to facilitate discharge planning, and communicate to outpatient providers the notable events of the hospitalization and anticipated post‐discharge needs.

• Utilize evidence based recommendations and protocols and risk stratification tools for the treatment of HAP.

SYSTEM ORGANIZATION AND IMPROVEMENT

To improve efficiency and quality within their organizations, Hospitalists should:

• Collaborate with local infection control practitioners to reduce the spread of resistant organisms within the institution.

• Lead, coordinate or participate in multidisciplinary initiatives, which may include collaboration with critical care specialists and pulmonologists, to reduce the incidence of hospital‐acquired pneumonia in ventilated patients.

• Lead, coordinate or participate in quality improvement initiatives to reduce ventilator days, rates of HAP, and variance in antibiotic use.

• Implement systems to ensure hospital‐wide adherence to national standards for empiric antibiotic use, and document those measures as specified by recognized organizations.

• Lead efforts to educate staff on the importance of smoking cessation counseling and other prevention measures.

Hospital‐acquired pneumonia (HAP) is an infection of the lung parenchyma that occurs during the course of hospitalization. HAP is a significant source of morbidity, mortality, and increased resource expenditures. The attributable mortality for hap is in the 3050 percent range. The primary risk factor for the development of HAP is mechanical ventilation. The average length of stay for patients with HAP increases by an average of 13 days, with estimated additional costs of $40,000. Hospitalists manage patients with HAP either as an attending physician or as a consultant to patients admitted to other services. Hospitalists can initiate quality improvement strategies at the individual patient level and at the system level to improve patient outcomes and optimize resource utilization.

KNOWLEDGE

Hospitalists should be able to:

• Define hospital‐acquired pneumonia (HAP).

• List common organisms associated with HAP.

• Describe local and national resistance patterns for HAP.

• Identify important historical elements, medical record data and physical examination findings consistent with HAP.

• Distinguish the infectious causes of HAP.

• Describe the indicated tests required to evaluate HAP.

• Identify patients at risk for developing HAP.

• Describe the role of mechanical ventilation as a risk factor for the development of HAP.

• Explain the prophylactic measures commonly used to lower the risk of HAP.

• Describe the role of mechanical ventilation as a potential treatment option for HAP.

• Describe infection control practices to prevent the spread of resistant organisms within the hospital.

• Describe potential complications of HAP.

• 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 perform a targeted physical examination for hospital‐acquired pneumonia.

• Order and interpret indicated laboratory, microbiologic and radiological studies to confirm diagnosis of hospital acquired pneumonia and determine the etiologic agent.

• Initiate empiric antibiotic regimen based on patient history and underlying co‐morbid conditions, likely organisms and local resistance patterns.

• Tailor antibiotic regimens based on microbiologic culture and sensitivity data as soon as available.

• Manage complications, which may include respiratory failure, pleural effusions and empyema.

• Coordinate care for patients requiring mechanical ventilation.

• Identify patients who require thoracentesis, perform or coordinate the procedure, and interpret the results.

• Assess patients with suspected hospital‐acquired pneumonia 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 etiology, management plan, and potential outcomes of hospital‐acquired pneumonia.

• Communicate with patients and families to explain the tests and procedures and their indications, and to obtain informed consent.

• Recognize indications for specialty consultation, which may include infectious disease and/or pulmonary services.

• Employ a multidisciplinary approach, which may include nursing, respiratory therapy, nutrition and pharmacy services, to the care of patients with HAP through all care transitions.

• Recognize steps that can be employed to limit the emergence of antibiotic resistance.

• Document treatment plan and provide clear discharge instructions for post‐discharge physicians.

• Recognize implications of HAP on discharge planning.

• Lead multidisciplinary teams to facilitate discharge planning, and communicate to outpatient providers the notable events of the hospitalization and anticipated post‐discharge needs.

• Utilize evidence based recommendations and protocols and risk stratification tools for the treatment of HAP.

SYSTEM ORGANIZATION AND IMPROVEMENT

To improve efficiency and quality within their organizations, Hospitalists should:

• Collaborate with local infection control practitioners to reduce the spread of resistant organisms within the institution.

• Lead, coordinate or participate in multidisciplinary initiatives, which may include collaboration with critical care specialists and pulmonologists, to reduce the incidence of hospital‐acquired pneumonia in ventilated patients.

• Lead, coordinate or participate in quality improvement initiatives to reduce ventilator days, rates of HAP, and variance in antibiotic use.

• Implement systems to ensure hospital‐wide adherence to national standards for empiric antibiotic use, and document those measures as specified by recognized organizations.

• Lead efforts to educate staff on the importance of smoking cessation counseling and other prevention measures.

Alcohol and drug withdrawal is a set of signs and symptoms that develop in association with a sudden cessation or taper in alcohol intake or use of prescription (particularly narcotic medications), over‐the‐counter (OTC), or illicit drugs. Withdrawal may occur prior to hospitalization or during the course of hospitalization. The Healthcare Cost and Utilization Project (HCUP) estimates 195,000 discharges for alcohol/drug abuse or dependency in 2002. These patients were hospitalized for a mean of 3.9 days with mean charges of $7,266 per patient. Hospitalists can lead their institutions in evidence based treatment protocols that improve care, reduce costs and length of stay, and facilitate better overall outcomes in patients with substance related withdrawal syndromes.

KNOWLEDGE

Hospitalists should be able to:

• Describe the effects of drug and alcohol withdrawal on medical illness and the effects of medical illness on substance withdrawal.

• Recognize the complications from substance use and dependency.

• Distinguish alcohol or drug withdrawal from other causes of delirium.

• Describe the indicated tests required to evaluate alcohol or drug withdrawal.

• Identify patients at increased risk for drug and alcohol withdrawal using current diagnostic criteria for withdrawal.

• Explain indications, contraindications and mechanisms of action of pharmacologic agents used to treat acute alcohol and drug withdrawal.

• Identify local trends in illicit drug use.

• Determine the best setting within the hospital to initiate, monitor, evaluate and treat patients with drug or alcohol withdrawal.

• Explain patient characteristics that on admission portend poor prognosis.

• Explain goals for hospital discharge, including specific measures of clinical stability for safe care transition.

SKILLS

Hospitalists should be able to:

• Elicit a thorough and relevant history, with emphasis on substance use.

• Recognize the symptoms and signs of alcohol and drug withdrawal, including prescription and OTC drugs.

• Differentiate delirium tremens from other alcohol withdrawal syndromes.

• Assess for common co‐morbidities in patients with a history of alcohol and drug use.

• Perform a rapid, efficient and targeted physical examination to assess alcohol or drug withdrawal and determine life‐threatening co‐morbidities.

• Apply DSM‐IV Diagnostic Criteria for Alcohol Withdrawal.

• Formulate a treatment plan, tailored to the individual patient, which may include appropriate pharmacologic agents and dosing, route of administration, and nutritional supplementation.

• Integrate existing literature and federal regulations into the management of patients with opioid withdrawal syndromes. for patients who are undergoing existing treatment for opioid dependency, communicate with outpatient treatment centers and integrate dosing regimens into care management.

• Manage withdrawal syndromes in patients with concomitant medical or surgical issues.

• Determine need for the use of restraints to ensure patient safety.

• Reassure, reorient, and frequently monitor the patient in a calm environment.

• Assess patients with suspected alcohol or drug withdrawal in a timely manner, identify the level of care required, and manage or co‐manage the patient with the primary requesting service.

ATTITUDES

Hospitalists should be able to:

• Use the acute hospitalization as an opportunity to counsel patients about abstinence, recovery and the medical risks of drug and alcohol use.

• Communicate with patients and families to explain goals of care plan, discharge instructions and management after release from hospital.

• Appreciate the indications for specialty consultations.

• Initiate prevention measures prior to discharge, including alcohol and drug cessation measures.

• Manage the hospitalized patient with substance use in a non‐judgmental manner.

• Employ a multidisciplinary approach, which may include psychiatry, pharmacy, nursing and social services, in the treatment of patients with substance use or dependency.

• Establish and maintain an open dialogue with patients and families regarding care goals and limitations.

• Appreciate and document the value of appropriate treatment in reducing mortality, duration of delirium, time required to control agitation, adequate control of delirium, treatment of complications, and cost.

• Facilitate discharge planning early in the hospitalization, including communicating with the primary care provider and presenting the patient with contact information for follow‐up care, support and rehabilitation.

• Utilize evidence based national recommendations to guide diagnosis, monitoring and treatment of withdrawal symptoms.

SYSTEM ORGANIZATION AND IMPROVEMENT

To improve efficiency and quality within their organizations, Hospitalists should:

• Lead, coordinate or participate in the development and promotion of guidelines and/or pathways that facilitate efficient and timely evaluation and treatment of patients with alcohol and drug withdrawal.

• Promote the development and use of evidence based guidelines and protocols for the treatment of withdrawal syndromes.

• Advocate for hospital resources to improve the care of patients with substance withdrawal, and the environment in which the care is delivered.

• Lead, coordinate or participate in multidisciplinary teams, which may include psychiatry, to improve patient safety and management strategies for patients with substance abuse.

Alcohol and drug withdrawal is a set of signs and symptoms that develop in association with a sudden cessation or taper in alcohol intake or use of prescription (particularly narcotic medications), over‐the‐counter (OTC), or illicit drugs. Withdrawal may occur prior to hospitalization or during the course of hospitalization. The Healthcare Cost and Utilization Project (HCUP) estimates 195,000 discharges for alcohol/drug abuse or dependency in 2002. These patients were hospitalized for a mean of 3.9 days with mean charges of $7,266 per patient. Hospitalists can lead their institutions in evidence based treatment protocols that improve care, reduce costs and length of stay, and facilitate better overall outcomes in patients with substance related withdrawal syndromes.

KNOWLEDGE

Hospitalists should be able to:

• Describe the effects of drug and alcohol withdrawal on medical illness and the effects of medical illness on substance withdrawal.

• Recognize the complications from substance use and dependency.

• Distinguish alcohol or drug withdrawal from other causes of delirium.

• Describe the indicated tests required to evaluate alcohol or drug withdrawal.

• Identify patients at increased risk for drug and alcohol withdrawal using current diagnostic criteria for withdrawal.

• Explain indications, contraindications and mechanisms of action of pharmacologic agents used to treat acute alcohol and drug withdrawal.

• Identify local trends in illicit drug use.

• Determine the best setting within the hospital to initiate, monitor, evaluate and treat patients with drug or alcohol withdrawal.

• Explain patient characteristics that on admission portend poor prognosis.

• Explain goals for hospital discharge, including specific measures of clinical stability for safe care transition.

SKILLS

Hospitalists should be able to:

• Elicit a thorough and relevant history, with emphasis on substance use.

• Recognize the symptoms and signs of alcohol and drug withdrawal, including prescription and OTC drugs.

• Differentiate delirium tremens from other alcohol withdrawal syndromes.

• Assess for common co‐morbidities in patients with a history of alcohol and drug use.

• Perform a rapid, efficient and targeted physical examination to assess alcohol or drug withdrawal and determine life‐threatening co‐morbidities.

• Apply DSM‐IV Diagnostic Criteria for Alcohol Withdrawal.

• Formulate a treatment plan, tailored to the individual patient, which may include appropriate pharmacologic agents and dosing, route of administration, and nutritional supplementation.

• Integrate existing literature and federal regulations into the management of patients with opioid withdrawal syndromes. for patients who are undergoing existing treatment for opioid dependency, communicate with outpatient treatment centers and integrate dosing regimens into care management.

• Manage withdrawal syndromes in patients with concomitant medical or surgical issues.

• Determine need for the use of restraints to ensure patient safety.

• Reassure, reorient, and frequently monitor the patient in a calm environment.

• Assess patients with suspected alcohol or drug withdrawal in a timely manner, identify the level of care required, and manage or co‐manage the patient with the primary requesting service.

ATTITUDES

Hospitalists should be able to:

• Use the acute hospitalization as an opportunity to counsel patients about abstinence, recovery and the medical risks of drug and alcohol use.

• Communicate with patients and families to explain goals of care plan, discharge instructions and management after release from hospital.

• Appreciate the indications for specialty consultations.

• Initiate prevention measures prior to discharge, including alcohol and drug cessation measures.

• Manage the hospitalized patient with substance use in a non‐judgmental manner.

• Employ a multidisciplinary approach, which may include psychiatry, pharmacy, nursing and social services, in the treatment of patients with substance use or dependency.

• Establish and maintain an open dialogue with patients and families regarding care goals and limitations.

• Appreciate and document the value of appropriate treatment in reducing mortality, duration of delirium, time required to control agitation, adequate control of delirium, treatment of complications, and cost.

• Facilitate discharge planning early in the hospitalization, including communicating with the primary care provider and presenting the patient with contact information for follow‐up care, support and rehabilitation.

• Utilize evidence based national recommendations to guide diagnosis, monitoring and treatment of withdrawal symptoms.

SYSTEM ORGANIZATION AND IMPROVEMENT

To improve efficiency and quality within their organizations, Hospitalists should:

• Lead, coordinate or participate in the development and promotion of guidelines and/or pathways that facilitate efficient and timely evaluation and treatment of patients with alcohol and drug withdrawal.

• Promote the development and use of evidence based guidelines and protocols for the treatment of withdrawal syndromes.

• Advocate for hospital resources to improve the care of patients with substance withdrawal, and the environment in which the care is delivered.

• Lead, coordinate or participate in multidisciplinary teams, which may include psychiatry, to improve patient safety and management strategies for patients with substance abuse.

Alcohol and drug withdrawal is a set of signs and symptoms that develop in association with a sudden cessation or taper in alcohol intake or use of prescription (particularly narcotic medications), over‐the‐counter (OTC), or illicit drugs. Withdrawal may occur prior to hospitalization or during the course of hospitalization. The Healthcare Cost and Utilization Project (HCUP) estimates 195,000 discharges for alcohol/drug abuse or dependency in 2002. These patients were hospitalized for a mean of 3.9 days with mean charges of $7,266 per patient. Hospitalists can lead their institutions in evidence based treatment protocols that improve care, reduce costs and length of stay, and facilitate better overall outcomes in patients with substance related withdrawal syndromes.

KNOWLEDGE

Hospitalists should be able to:

• Describe the effects of drug and alcohol withdrawal on medical illness and the effects of medical illness on substance withdrawal.

• Recognize the complications from substance use and dependency.

• Distinguish alcohol or drug withdrawal from other causes of delirium.

• Describe the indicated tests required to evaluate alcohol or drug withdrawal.

• Identify patients at increased risk for drug and alcohol withdrawal using current diagnostic criteria for withdrawal.

• Explain indications, contraindications and mechanisms of action of pharmacologic agents used to treat acute alcohol and drug withdrawal.

• Identify local trends in illicit drug use.

• Determine the best setting within the hospital to initiate, monitor, evaluate and treat patients with drug or alcohol withdrawal.

• Explain patient characteristics that on admission portend poor prognosis.

• Explain goals for hospital discharge, including specific measures of clinical stability for safe care transition.

SKILLS

Hospitalists should be able to:

• Elicit a thorough and relevant history, with emphasis on substance use.

• Recognize the symptoms and signs of alcohol and drug withdrawal, including prescription and OTC drugs.

• Differentiate delirium tremens from other alcohol withdrawal syndromes.

• Assess for common co‐morbidities in patients with a history of alcohol and drug use.

• Perform a rapid, efficient and targeted physical examination to assess alcohol or drug withdrawal and determine life‐threatening co‐morbidities.

• Apply DSM‐IV Diagnostic Criteria for Alcohol Withdrawal.

• Formulate a treatment plan, tailored to the individual patient, which may include appropriate pharmacologic agents and dosing, route of administration, and nutritional supplementation.

• Integrate existing literature and federal regulations into the management of patients with opioid withdrawal syndromes. for patients who are undergoing existing treatment for opioid dependency, communicate with outpatient treatment centers and integrate dosing regimens into care management.

• Manage withdrawal syndromes in patients with concomitant medical or surgical issues.

• Determine need for the use of restraints to ensure patient safety.

• Reassure, reorient, and frequently monitor the patient in a calm environment.

• Assess patients with suspected alcohol or drug withdrawal in a timely manner, identify the level of care required, and manage or co‐manage the patient with the primary requesting service.

ATTITUDES

Hospitalists should be able to:

• Use the acute hospitalization as an opportunity to counsel patients about abstinence, recovery and the medical risks of drug and alcohol use.

• Communicate with patients and families to explain goals of care plan, discharge instructions and management after release from hospital.

• Appreciate the indications for specialty consultations.

• Initiate prevention measures prior to discharge, including alcohol and drug cessation measures.

• Manage the hospitalized patient with substance use in a non‐judgmental manner.

• Employ a multidisciplinary approach, which may include psychiatry, pharmacy, nursing and social services, in the treatment of patients with substance use or dependency.

• Establish and maintain an open dialogue with patients and families regarding care goals and limitations.

• Appreciate and document the value of appropriate treatment in reducing mortality, duration of delirium, time required to control agitation, adequate control of delirium, treatment of complications, and cost.

• Facilitate discharge planning early in the hospitalization, including communicating with the primary care provider and presenting the patient with contact information for follow‐up care, support and rehabilitation.

• Utilize evidence based national recommendations to guide diagnosis, monitoring and treatment of withdrawal symptoms.

SYSTEM ORGANIZATION AND IMPROVEMENT

To improve efficiency and quality within their organizations, Hospitalists should:

• Lead, coordinate or participate in the development and promotion of guidelines and/or pathways that facilitate efficient and timely evaluation and treatment of patients with alcohol and drug withdrawal.

• Promote the development and use of evidence based guidelines and protocols for the treatment of withdrawal syndromes.

• Advocate for hospital resources to improve the care of patients with substance withdrawal, and the environment in which the care is delivered.

• Lead, coordinate or participate in multidisciplinary teams, which may include psychiatry, to improve patient safety and management strategies for patients with substance abuse.

Patients age 65 years or older represent over 30% of acute care hospitalizations and 50% of hospital expenditures. The hospitalized elder is at risk for a multitude of poor outcomes, which may include increased mortality, prolonged length of stay, high rates of readmission, skilled nursing facility placement, and delirium and functional decline. These outcomes have significant medical, psychosocial, and economic impact on individual patients and families as well as on the healthcare system in general. In addition to disease‐based management, care of the elderly must be approached within a specific psychosocial and functional context. Hospitalists engage in a collaborative, multidisciplinary approach to the care of elderly patients that begins at the time of hospital admission and continues through all care transitions. Hospitalists can lead initiatives that improve the care of elderly patients.

KNOWLEDGE

Hospitalists should be able to:

• Describe the complications related to hospitalization in the elderly.

• Describe the environmental or iatrogenic factors that may contribute to complications in the hospitalized elderly.

• List medications with potential to cause adverse drug reactions in the elderly.

• Describe interventions that can decrease rates of poor outcomes in the hospitalized elderly.

• Explain the key elements of the discharge planning process and options for post‐acute care.

• Describe the multiple options for transition from the acute care hospital that can assist patients in regaining functional capacity.

• List patient‐specific risk factors for complications in the hospitalized elderly.

SKILLS

Hospitalists should be able to:

• Perform a thorough history and physical examination to identify patient risk factors for complications during hospitalization.

• Perform a brief cognitive and functional assessment of the elderly patient.

• Use active measures to prevent, identify, evaluate and treat pressure ulcers.

• Formulate multidisciplinary care plans for the prevention of delirium, falls, and functional decline.

• Provide non‐pharmacologic alternatives for the management of agitation, insomnia, and delirium.

• Prescribe medications for the behavioral symptoms of delirium or dementia that cannot be controlled with non‐pharmacologic management.

• Perform a social assessment of the patient's living conditions/support systems and understand how that impacts the patient's health and care plan.

• Formulate safe multidisciplinary plans for care transitions for elderly patients with complex discharge needs.

• Incorporate unique characteristics of elderly patients into the development of therapeutic plans.

• Recognize signs of potential elder abuse.

ATTITUDES

Hospitalists should be able to:

• Appreciate the complications and potential adverse effects associated with polypharmacy.

• Educate patients and families about individual measures and community resources that can reduce potential complications after discharge.

• Appreciate the risks and complications associated with restraint use.

• Appreciate the concept of transitional care.

• Participate actively in multidisciplinary team meetings to formulate coordinated care plans for acute hospitalization and care transitions.

• Promote a team approach to the care of the hospitalized elder, which may include physicians, nurses, pharmacists, social workers, and rehabilitation services.

• Appreciate the medical, psychosocial and economic impact of hospitalization on elderly patients and their families.

• Establish and maintain an open dialogue with patients and families regarding care goals and limitations, palliative care, and end of life issues, including living wills.

• Connect elderly patients with social services early in the hospital course to provide institutional support, which may include referral for insurance and drug benefits, transportation, mental health services and substance abuse services.

• Communicate effectively with primary care physicians and other post‐acute care providers to promote safe, coordinated care transitions.

• Lead, coordinate or participate in multidisciplinary hospital initiatives to develop prevention programs and standardized treatment algorithms for elder outcomes such as delirium, falls, functional decline, and pressure ulcers.

• Lead, coordinate or participate in hospital initiatives to improve care transitions and reduce poor discharge outcomes in the elderly.

• Lead, coordinate or participate in patient safety initiatives to reduce common elder complications in the hospital.

Patients age 65 years or older represent over 30% of acute care hospitalizations and 50% of hospital expenditures. The hospitalized elder is at risk for a multitude of poor outcomes, which may include increased mortality, prolonged length of stay, high rates of readmission, skilled nursing facility placement, and delirium and functional decline. These outcomes have significant medical, psychosocial, and economic impact on individual patients and families as well as on the healthcare system in general. In addition to disease‐based management, care of the elderly must be approached within a specific psychosocial and functional context. Hospitalists engage in a collaborative, multidisciplinary approach to the care of elderly patients that begins at the time of hospital admission and continues through all care transitions. Hospitalists can lead initiatives that improve the care of elderly patients.

KNOWLEDGE

Hospitalists should be able to:

• Describe the complications related to hospitalization in the elderly.

• Describe the environmental or iatrogenic factors that may contribute to complications in the hospitalized elderly.

• List medications with potential to cause adverse drug reactions in the elderly.

• Describe interventions that can decrease rates of poor outcomes in the hospitalized elderly.

• Explain the key elements of the discharge planning process and options for post‐acute care.

• Describe the multiple options for transition from the acute care hospital that can assist patients in regaining functional capacity.

• List patient‐specific risk factors for complications in the hospitalized elderly.

SKILLS

Hospitalists should be able to:

• Perform a thorough history and physical examination to identify patient risk factors for complications during hospitalization.

• Perform a brief cognitive and functional assessment of the elderly patient.

• Use active measures to prevent, identify, evaluate and treat pressure ulcers.

• Formulate multidisciplinary care plans for the prevention of delirium, falls, and functional decline.

• Provide non‐pharmacologic alternatives for the management of agitation, insomnia, and delirium.

• Prescribe medications for the behavioral symptoms of delirium or dementia that cannot be controlled with non‐pharmacologic management.

• Perform a social assessment of the patient's living conditions/support systems and understand how that impacts the patient's health and care plan.

• Formulate safe multidisciplinary plans for care transitions for elderly patients with complex discharge needs.

• Incorporate unique characteristics of elderly patients into the development of therapeutic plans.

• Recognize signs of potential elder abuse.

ATTITUDES

Hospitalists should be able to:

• Appreciate the complications and potential adverse effects associated with polypharmacy.

• Educate patients and families about individual measures and community resources that can reduce potential complications after discharge.

• Appreciate the risks and complications associated with restraint use.

• Appreciate the concept of transitional care.

• Participate actively in multidisciplinary team meetings to formulate coordinated care plans for acute hospitalization and care transitions.

• Promote a team approach to the care of the hospitalized elder, which may include physicians, nurses, pharmacists, social workers, and rehabilitation services.

• Appreciate the medical, psychosocial and economic impact of hospitalization on elderly patients and their families.

• Establish and maintain an open dialogue with patients and families regarding care goals and limitations, palliative care, and end of life issues, including living wills.

• Connect elderly patients with social services early in the hospital course to provide institutional support, which may include referral for insurance and drug benefits, transportation, mental health services and substance abuse services.

• Communicate effectively with primary care physicians and other post‐acute care providers to promote safe, coordinated care transitions.

• Lead, coordinate or participate in multidisciplinary hospital initiatives to develop prevention programs and standardized treatment algorithms for elder outcomes such as delirium, falls, functional decline, and pressure ulcers.

• Lead, coordinate or participate in hospital initiatives to improve care transitions and reduce poor discharge outcomes in the elderly.

• Lead, coordinate or participate in patient safety initiatives to reduce common elder complications in the hospital.

Patients age 65 years or older represent over 30% of acute care hospitalizations and 50% of hospital expenditures. The hospitalized elder is at risk for a multitude of poor outcomes, which may include increased mortality, prolonged length of stay, high rates of readmission, skilled nursing facility placement, and delirium and functional decline. These outcomes have significant medical, psychosocial, and economic impact on individual patients and families as well as on the healthcare system in general. In addition to disease‐based management, care of the elderly must be approached within a specific psychosocial and functional context. Hospitalists engage in a collaborative, multidisciplinary approach to the care of elderly patients that begins at the time of hospital admission and continues through all care transitions. Hospitalists can lead initiatives that improve the care of elderly patients.

KNOWLEDGE

Hospitalists should be able to:

• Describe the complications related to hospitalization in the elderly.

• Describe the environmental or iatrogenic factors that may contribute to complications in the hospitalized elderly.

• List medications with potential to cause adverse drug reactions in the elderly.

• Describe interventions that can decrease rates of poor outcomes in the hospitalized elderly.

• Explain the key elements of the discharge planning process and options for post‐acute care.

• Describe the multiple options for transition from the acute care hospital that can assist patients in regaining functional capacity.

• List patient‐specific risk factors for complications in the hospitalized elderly.

SKILLS

Hospitalists should be able to:

• Perform a thorough history and physical examination to identify patient risk factors for complications during hospitalization.

• Perform a brief cognitive and functional assessment of the elderly patient.

• Use active measures to prevent, identify, evaluate and treat pressure ulcers.

• Formulate multidisciplinary care plans for the prevention of delirium, falls, and functional decline.

• Provide non‐pharmacologic alternatives for the management of agitation, insomnia, and delirium.

• Prescribe medications for the behavioral symptoms of delirium or dementia that cannot be controlled with non‐pharmacologic management.

• Perform a social assessment of the patient's living conditions/support systems and understand how that impacts the patient's health and care plan.

• Formulate safe multidisciplinary plans for care transitions for elderly patients with complex discharge needs.

• Incorporate unique characteristics of elderly patients into the development of therapeutic plans.

• Recognize signs of potential elder abuse.

ATTITUDES

Hospitalists should be able to:

• Appreciate the complications and potential adverse effects associated with polypharmacy.

• Educate patients and families about individual measures and community resources that can reduce potential complications after discharge.

• Appreciate the risks and complications associated with restraint use.

• Appreciate the concept of transitional care.

• Participate actively in multidisciplinary team meetings to formulate coordinated care plans for acute hospitalization and care transitions.

• Promote a team approach to the care of the hospitalized elder, which may include physicians, nurses, pharmacists, social workers, and rehabilitation services.

• Appreciate the medical, psychosocial and economic impact of hospitalization on elderly patients and their families.

• Establish and maintain an open dialogue with patients and families regarding care goals and limitations, palliative care, and end of life issues, including living wills.

• Connect elderly patients with social services early in the hospital course to provide institutional support, which may include referral for insurance and drug benefits, transportation, mental health services and substance abuse services.

• Communicate effectively with primary care physicians and other post‐acute care providers to promote safe, coordinated care transitions.

• Lead, coordinate or participate in multidisciplinary hospital initiatives to develop prevention programs and standardized treatment algorithms for elder outcomes such as delirium, falls, functional decline, and pressure ulcers.

• Lead, coordinate or participate in hospital initiatives to improve care transitions and reduce poor discharge outcomes in the elderly.

• Lead, coordinate or participate in patient safety initiatives to reduce common elder complications in the hospital.

Health care expenditures in the United States continue to rise, reaching over $1.4 trillion in 2001 (14% of the gross domestic product), with hospital spending accounting for the largest portion. Hospitals are under constant pressure to provide more efficient care with limited resources. As hospitalists provide cost‐effective inpatient care, they increasingly act as coordinators of care and resources in the hospital setting. Among the factors that make patients vulnerable to inequitable health care are race, ethnicity, and socioeconomic status. While disparity in care exists in United States hospitals, hospitalists are positioned to identify such disparities, optimize care for all patients, and advocate for equitable and cost‐effective allocation of hospital resources.

KNOWLEDGE

Hospitalists should be able to:

• Define the concepts of equity and cost‐effectiveness.

• Identify patient populations at risk for inequitable health care.

• Recognize health resources that are prone to inequitable allocations.

• Distinguish between decision analysis, cost‐effectiveness analysis, and cost‐benefit analysis.

• Explain how cost‐effectiveness may conflict with equity in health care policies.

• Discuss how stereotypes impact the allocation of health resources.

• Demonstrate how equity in health care is cost effective.

• Illustrate how disparities in health care are related to quality of care.

SKILLS

Hospitalists should be able to:

• Measure patient access to hospital resources.

• Incorporate equity concerns into cost‐effectiveness analysis.

• Triage patients to appropriate hospital resources.

• Construct cost‐effective care pathways that allocate resources equitably.

• Monitor for equity in health care among hospitalized patients.

• Practice evidence based, cost‐effective care for all patients.

ATTITUDES

Hospitalists should be able to:

• Listen to the concerns of all patients.

• Advocate for every patient's needed health services.

• Influence hospital policy to ensure equitable health care coverage for all hospitalized patients.

• Act on cultural differences or language barriers during patient encounters that may inhibit equality in health care.

• Recognize that over utilization of resources including excessive test ordering may not promote patient safety or patient satisfaction, or improve quality of care.

• Lead, coordinate or participate in multidisciplinary teams, which may include radiology, pharmacy, nursing and social services to decrease hospital costs and provide evidence based, cost effective care.

• Collaborate with information technologists and health care economists to track utilization and outcomes. Lead, coordinate or participate in quality improvement initiatives to improve resource allocation.

• Advocate using cost‐effectiveness analysis, cost benefit analysis, evidence based medicine and measurements of health care equity to mold hospital policy on the allocation of its resources.

• Advocate for cross‐cultural education and interpreter services into hospital systems to decrease barriers to equitable health care allocations.

• Lead, coordinate, or participate in multidisciplinary hospital and community efforts to ensure proper access to care for all individuals.

Health care expenditures in the United States continue to rise, reaching over $1.4 trillion in 2001 (14% of the gross domestic product), with hospital spending accounting for the largest portion. Hospitals are under constant pressure to provide more efficient care with limited resources. As hospitalists provide cost‐effective inpatient care, they increasingly act as coordinators of care and resources in the hospital setting. Among the factors that make patients vulnerable to inequitable health care are race, ethnicity, and socioeconomic status. While disparity in care exists in United States hospitals, hospitalists are positioned to identify such disparities, optimize care for all patients, and advocate for equitable and cost‐effective allocation of hospital resources.

KNOWLEDGE

Hospitalists should be able to:

• Define the concepts of equity and cost‐effectiveness.

• Identify patient populations at risk for inequitable health care.

• Recognize health resources that are prone to inequitable allocations.

• Distinguish between decision analysis, cost‐effectiveness analysis, and cost‐benefit analysis.

• Explain how cost‐effectiveness may conflict with equity in health care policies.

• Discuss how stereotypes impact the allocation of health resources.

• Demonstrate how equity in health care is cost effective.

• Illustrate how disparities in health care are related to quality of care.

SKILLS

Hospitalists should be able to:

• Measure patient access to hospital resources.

• Incorporate equity concerns into cost‐effectiveness analysis.

• Triage patients to appropriate hospital resources.

• Construct cost‐effective care pathways that allocate resources equitably.

• Monitor for equity in health care among hospitalized patients.

• Practice evidence based, cost‐effective care for all patients.

ATTITUDES

Hospitalists should be able to:

• Listen to the concerns of all patients.

• Advocate for every patient's needed health services.

• Influence hospital policy to ensure equitable health care coverage for all hospitalized patients.

• Act on cultural differences or language barriers during patient encounters that may inhibit equality in health care.

• Recognize that over utilization of resources including excessive test ordering may not promote patient safety or patient satisfaction, or improve quality of care.

• Lead, coordinate or participate in multidisciplinary teams, which may include radiology, pharmacy, nursing and social services to decrease hospital costs and provide evidence based, cost effective care.

• Collaborate with information technologists and health care economists to track utilization and outcomes. Lead, coordinate or participate in quality improvement initiatives to improve resource allocation.

• Advocate using cost‐effectiveness analysis, cost benefit analysis, evidence based medicine and measurements of health care equity to mold hospital policy on the allocation of its resources.

• Advocate for cross‐cultural education and interpreter services into hospital systems to decrease barriers to equitable health care allocations.

• Lead, coordinate, or participate in multidisciplinary hospital and community efforts to ensure proper access to care for all individuals.

Health care expenditures in the United States continue to rise, reaching over $1.4 trillion in 2001 (14% of the gross domestic product), with hospital spending accounting for the largest portion. Hospitals are under constant pressure to provide more efficient care with limited resources. As hospitalists provide cost‐effective inpatient care, they increasingly act as coordinators of care and resources in the hospital setting. Among the factors that make patients vulnerable to inequitable health care are race, ethnicity, and socioeconomic status. While disparity in care exists in United States hospitals, hospitalists are positioned to identify such disparities, optimize care for all patients, and advocate for equitable and cost‐effective allocation of hospital resources.

KNOWLEDGE

Hospitalists should be able to:

• Define the concepts of equity and cost‐effectiveness.

• Identify patient populations at risk for inequitable health care.

• Recognize health resources that are prone to inequitable allocations.

• Distinguish between decision analysis, cost‐effectiveness analysis, and cost‐benefit analysis.

• Explain how cost‐effectiveness may conflict with equity in health care policies.

• Discuss how stereotypes impact the allocation of health resources.

• Demonstrate how equity in health care is cost effective.

• Illustrate how disparities in health care are related to quality of care.

SKILLS

Hospitalists should be able to:

• Measure patient access to hospital resources.

• Incorporate equity concerns into cost‐effectiveness analysis.

• Triage patients to appropriate hospital resources.

• Construct cost‐effective care pathways that allocate resources equitably.

• Monitor for equity in health care among hospitalized patients.

• Practice evidence based, cost‐effective care for all patients.

ATTITUDES

Hospitalists should be able to:

• Listen to the concerns of all patients.

• Advocate for every patient's needed health services.

• Influence hospital policy to ensure equitable health care coverage for all hospitalized patients.

• Act on cultural differences or language barriers during patient encounters that may inhibit equality in health care.

• Recognize that over utilization of resources including excessive test ordering may not promote patient safety or patient satisfaction, or improve quality of care.

• Lead, coordinate or participate in multidisciplinary teams, which may include radiology, pharmacy, nursing and social services to decrease hospital costs and provide evidence based, cost effective care.

• Collaborate with information technologists and health care economists to track utilization and outcomes. Lead, coordinate or participate in quality improvement initiatives to improve resource allocation.

• Advocate using cost‐effectiveness analysis, cost benefit analysis, evidence based medicine and measurements of health care equity to mold hospital policy on the allocation of its resources.

• Advocate for cross‐cultural education and interpreter services into hospital systems to decrease barriers to equitable health care allocations.

• Lead, coordinate, or participate in multidisciplinary hospital and community efforts to ensure proper access to care for all individuals.

ABG Arterial blood gas

ACLS Advanced cardiac life support

ACS Acute coronary syndrome

ADE Adverse drug event

ARF Acute renal failures

ARR Absolute risk reduction

BLS Basic life support

CAD Coronary artery disease

CAP Community acquired pneumonia

CHF Congestive heart failure

CNS Central nervous system

COPD Chronic obstructive pulmonary disease

CPOE Computer physician order entry

CSF Cerebrospinal fluid

CT Computed tomography

CXR Chest radiograph

DKA Diabetic ketoacidosis

DSM‐IV Diagnostic and Statistical Manual of Mental Disorders (4^th edition)

DVT Deep vein thrombosis

EBM Evidence based medicine

EKG Electrocardiogram

FMEA Failure mode and effects analysis

GI Gastrointestinal

HAP Hospital acquired pneumonia

HHS Hyperglycemia hyperosmolar state

ICU Intensive care unit

MRI Magnetic resonance imaging

NNT Number needed to treat

NSAIDS Nonsteroidal anti‐inflammatory drugs

NSTEMI Non‐ST‐segment elevation myocardial infarction

OTC Over‐the‐counter drugs

PBLI Practice based learning and improvement

PE Pulmonary embolus

PDI Pneumonia severity index

PORT Pneumonia patient outcomes research team

PDSA Plan Do Study Act

PSI Pneumonia Severity Index

QI Quality Improvement

RCA Root cause analysis

RRR Relative risk reduction

RVU Relative value units

STEMI ST‐elevation myocardial infarction

SIRS Systemic Inflammatory Response Syndrome

UTI Urinary tract infection

VTE Venous thromboembolism

ABG Arterial blood gas

ACLS Advanced cardiac life support

ACS Acute coronary syndrome

ADE Adverse drug event

ARF Acute renal failures

ARR Absolute risk reduction

BLS Basic life support

CAD Coronary artery disease

CAP Community acquired pneumonia

CHF Congestive heart failure

CNS Central nervous system

COPD Chronic obstructive pulmonary disease

CPOE Computer physician order entry

CSF Cerebrospinal fluid

CT Computed tomography

CXR Chest radiograph

DKA Diabetic ketoacidosis

DSM‐IV Diagnostic and Statistical Manual of Mental Disorders (4^th edition)

DVT Deep vein thrombosis

EBM Evidence based medicine

EKG Electrocardiogram

FMEA Failure mode and effects analysis

GI Gastrointestinal

HAP Hospital acquired pneumonia

HHS Hyperglycemia hyperosmolar state

ICU Intensive care unit

MRI Magnetic resonance imaging

NNT Number needed to treat

NSAIDS Nonsteroidal anti‐inflammatory drugs

NSTEMI Non‐ST‐segment elevation myocardial infarction

OTC Over‐the‐counter drugs

PBLI Practice based learning and improvement

PE Pulmonary embolus

PDI Pneumonia severity index

PORT Pneumonia patient outcomes research team

PDSA Plan Do Study Act

PSI Pneumonia Severity Index

QI Quality Improvement

RCA Root cause analysis

RRR Relative risk reduction

RVU Relative value units

STEMI ST‐elevation myocardial infarction

SIRS Systemic Inflammatory Response Syndrome

UTI Urinary tract infection

VTE Venous thromboembolism

ABG Arterial blood gas

ACLS Advanced cardiac life support

ACS Acute coronary syndrome

ADE Adverse drug event

ARF Acute renal failures

ARR Absolute risk reduction

BLS Basic life support

CAD Coronary artery disease

CAP Community acquired pneumonia

CHF Congestive heart failure

CNS Central nervous system

COPD Chronic obstructive pulmonary disease

CPOE Computer physician order entry

CSF Cerebrospinal fluid

CT Computed tomography

CXR Chest radiograph

DKA Diabetic ketoacidosis

DSM‐IV Diagnostic and Statistical Manual of Mental Disorders (4^th edition)

DVT Deep vein thrombosis

EBM Evidence based medicine

EKG Electrocardiogram

FMEA Failure mode and effects analysis

GI Gastrointestinal

HAP Hospital acquired pneumonia

HHS Hyperglycemia hyperosmolar state

ICU Intensive care unit

MRI Magnetic resonance imaging

NNT Number needed to treat

NSAIDS Nonsteroidal anti‐inflammatory drugs

NSTEMI Non‐ST‐segment elevation myocardial infarction

OTC Over‐the‐counter drugs

PBLI Practice based learning and improvement

PE Pulmonary embolus

PDI Pneumonia severity index

PORT Pneumonia patient outcomes research team

PDSA Plan Do Study Act

PSI Pneumonia Severity Index

QI Quality Improvement

RCA Root cause analysis

RRR Relative risk reduction

RVU Relative value units

STEMI ST‐elevation myocardial infarction

SIRS Systemic Inflammatory Response Syndrome

UTI Urinary tract infection

VTE Venous thromboembolism

In Hospital Medicine, emergency procedures refer to advanced cardiac life support (ACLS), endotracheal intubation, and short‐term mechanical ventilation. Hospitalists care for patients admitted to the hospital with critical illnesses, as well as patients who have become critically ill during their hospital stay. In providing care to patients who have become critically ill, many Hospitalists perform or supervise these emergency procedures. Hospitalists lead efforts to provide timely, standardized response to inpatient emergencies.

CARDIOPULMONARY RESUSCITATION

KNOWLEDGE

Hospitalists should be able to:

• Describe the normal anatomy of the oral cavity, airway, thorax, heart and lungs.

• Describe the clinical findings or disease processes that require implementation of cardiopulmonary resuscitation and advanced life support.

• Describe clinical or cardiac rhythm findings that may impact outcomes for patients with cardiopulmonary arrest.

• List the laboratory and other diagnostic tests indicated during cardiopulmonary distress or arrest and immediately following successful resuscitation.

• Explain basic life support (BLS) protocols.

• Explain and differentiate current ACLS protocols, including the indicated interventions, based on the clinical situation and cardiac rhythm.

• Select the necessary equipment to manage the airway, identify cardiac rhythms, and perform defibrillation.

• Explain which cardiac rhythms and clinical situations require immediate defibrillation.

• Explain the mechanisms of action and uses of medications employed during ACLS.

• Explain the indications for procedural interventions that may be employed during the course of resuscitation.

• Explain the role of hyperthermia as a neuro‐protective measure in the post‐resuscitation period.

SKILLS

Hospitalists should be able to:

• Promptly identify acute cardiopulmonary distress or arrest, and call for assistance.

• Assess the patient, rapidly review the situation, and develop a differential diagnosis of etiology.

• Elicit additional history from the patient's family, other healthcare providers, and the patient's chart when available.

• Clearly and rapidly identify the event leader, and delineate other staff roles at the beginning of the resuscitation event.

• Properly position the patient on a backboard to perform BLS and ACLS protocols.

• Continually reassess proper patient positioning during resuscitation.

• Perform BLS protocols to open the airway, use a bag‐valve‐mask ventilatory device, and perform external chest compressions.

• Attach a defibrillator/pacer pads to the patient, and explain the operation of manual and automated defibrillators and external pacing systems.

• Maintain clinician safety with appropriate protective wear.

• Interpret cardiac rhythms and other diagnostic indicators.

• Synthesize diagnostic information to deliver medications and/or defibrillation, and perform procedures required during resuscitation efforts.

ATTITUDES

Hospitalists should be able to:

• Assess and respect the wishes of patients and families who desire no or limited resuscitation measures during hospitalization.

• Communicate with families to explain the efforts performed as well as outcomes and next steps.

• Rapidly respond to emergencies without distraction.

• Facilitate interactions between healthcare professionals about the roles that each will perform during the resuscitation effort.

• Review the resuscitation documentation for accuracy immediately following the event.

• Recognize the indications for emergent specialty consultation when available, which may include ENT, surgery, or critical care medicine.

• Appreciate the value of spiritual support services during and following resuscitation efforts.

• Discontinue resuscitation efforts when interventions have been unsuccessful and continued efforts are medically futile.

• Arrange for appropriate care transitions following successful resuscitation.

• Address family wishes regarding organ donation and autopsy.

ENDOTRACHEAL INTUBATION

KNOWLEDGE

Hospitalists should be able to:

• Describe the anatomy of the oral cavity, posterior pharynx and larynx.

• Describe clinical findings or disease processes that may require securing an airway.

• Describe the indications and contraindications, benefits and risks of endotracheal intubation.

• Describe the necessary equipment and medications required for routine and difficult intubations.

• Describe the process of endotracheal intubation from laryngoscope assembly to assessment of tube placement.

• Describe and differentiate alternatives to endotracheal intubation.

SKILLS

Hospitalists should be able to:

• Identify patients for whom endotracheal intubation may be required.

• Utilize bag‐valve‐mask ventilation with oral or nasal airway as a bridge to intubation.

• Select the appropriate laryngoscope blade for the individual patient.

• Position the patient and the bed for optimal procedure success and operator comfort.

• Assemble the laryngoscope and intubate the patient after visualizing the vocal cords.

• Prepare the oropharynx for intubation using necessary steps that may include removal of oral hardware, suctioning, and application of cricoid pressure.

• Request cricoid pressure and other maneuvers when indicated.

• Place the endotracheal tube at an appropriate depth in the airway.

• Confirm endotracheal tube placement by gastric and breath sounds, carbon dioxide monitor, and radiography; adjust tube position when indicated.

ATTITUDES

Hospitalists should be able to:

• Communicate with patients and families regarding procedure indications and next steps in management.

• Maintain high oxygen saturation prior to intubation whenever possible.

• Minimize patient trauma risk during intubations.

• Appreciate that bag‐valve‐mask can provide adequate oxygenation for extended periods when difficult intubations are delayed.

• Maintain clinician safety with appropriate protective wear.

• Use an alternative airway control device (e.g. laryngeal mask airway) for patients with difficult or unsuccessful intubations.

• Request appropriate specialist consultation for difficult or unsuccessful intubations or when clinician experience level precludes intubation trial.

MECHANICAL VENTILATION

KNOWLEDGE

Hospitalists should be able to:

• Describe the normal anatomy of the chest wall, thorax, and lung.

• Describe disease processes that lead to respiratory failure and expected clinical findings.

• Describe the indications, benefits and risks of mechanical ventilation.

• Describe indications and contraindications for non‐invasive ventilation in selected patients.

• Explain the role of arterial blood gas (ABG) analysis in the management of ventilated patients.

• Describe available modes of ventilation, and how to select initial and subsequent ventilator settings.

• Describe methods of and indications for sedation, comfort management, and/or paralysis in ventilated patients.

• Describe various ventilator settings and explain the use of individual settings based on the patient's disease process and clinical condition.

SKILLS

Hospitalists should be able to:

• Utilize nursing and respiratory therapy reports, physical examination, and ventilator data to identify complications due to mechanical ventilation.

• Select and adjust the ventilator mode and settings based on underlying disease process, other patient factors, ventilator data, and ABG analysis.

• Employ indicated interventions when complications of mechanical ventilation are identified.

• Identify the components of the ventilator, assess proper functioning, and identify equipment malfunction and/or patient‐ventilator dysynchrony.

• Order and interpret laboratory and imaging studies based on changes in patient's clinical status.

• Order adequate sedation and other indicated interventions to treat underlying conditions leading to respiratory failure and to prevent the complications of mechanical ventilation.

ATTITUDES

Hospitalists should be able to:

• Communicate with patients and/or families to explain the risks, benefits, and alternatives to invasive ventilation.

• Obtain informed consent prior to non‐emergent intubations.

• Conduct regular family meetings to provide clinical updates and facilitate shared decision‐making.

• Implement interventions shown to reduce risk of ventilator‐associated complications, which may include hospital acquired pneumonia, stress ulceration and bleeding, and venous thromboembolism.

• Provide adequate sedation, comfort management, and paralysis when indicated for patients requiring mechanical ventilation.

• Recognize the indications for specialty consultation, which may include critical care medicine.

SYSTEM ORGANIZATION AND IMPROVEMENT FOR EMERGENCY PROCEDURES

To improve efficiency and quality within their organizations, Hospitalists should:

• Collaborate with critical care physicians, respiratory therapists, and critical care nurses to develop evidence based protocols or guidelines for optimal ventilator management and weaning.

• Lead, coordinate or participate in evaluation of resuscitation and mechanical ventilation outcomes and identify and implement improvement initiatives.

• Lead, coordinate or participate in multidisciplinary teams, which may include critical care nurses, respiratory therapists, and critical care and emergency physicians, to establish ongoing training to ensure high quality performance of emergency procedures.

• Lead, coordinate or participate in multidisciplinary efforts to review antecedent events to identify changes in clinical status which, if promptly identified and acted upon, may have prevented the emergency intervention.

• Facilitate appropriate organization and consolidation of equipment in multiple identifiable and accessible locations in the hospital for performance of emergency procedures.

In Hospital Medicine, emergency procedures refer to advanced cardiac life support (ACLS), endotracheal intubation, and short‐term mechanical ventilation. Hospitalists care for patients admitted to the hospital with critical illnesses, as well as patients who have become critically ill during their hospital stay. In providing care to patients who have become critically ill, many Hospitalists perform or supervise these emergency procedures. Hospitalists lead efforts to provide timely, standardized response to inpatient emergencies.

CARDIOPULMONARY RESUSCITATION

KNOWLEDGE

Hospitalists should be able to:

• Describe the normal anatomy of the oral cavity, airway, thorax, heart and lungs.

• Describe the clinical findings or disease processes that require implementation of cardiopulmonary resuscitation and advanced life support.

• Describe clinical or cardiac rhythm findings that may impact outcomes for patients with cardiopulmonary arrest.

• List the laboratory and other diagnostic tests indicated during cardiopulmonary distress or arrest and immediately following successful resuscitation.

• Explain basic life support (BLS) protocols.

• Explain and differentiate current ACLS protocols, including the indicated interventions, based on the clinical situation and cardiac rhythm.

• Select the necessary equipment to manage the airway, identify cardiac rhythms, and perform defibrillation.

• Explain which cardiac rhythms and clinical situations require immediate defibrillation.

• Explain the mechanisms of action and uses of medications employed during ACLS.

• Explain the indications for procedural interventions that may be employed during the course of resuscitation.

• Explain the role of hyperthermia as a neuro‐protective measure in the post‐resuscitation period.

SKILLS

Hospitalists should be able to:

• Promptly identify acute cardiopulmonary distress or arrest, and call for assistance.

• Assess the patient, rapidly review the situation, and develop a differential diagnosis of etiology.

• Elicit additional history from the patient's family, other healthcare providers, and the patient's chart when available.

• Clearly and rapidly identify the event leader, and delineate other staff roles at the beginning of the resuscitation event.

• Properly position the patient on a backboard to perform BLS and ACLS protocols.

• Continually reassess proper patient positioning during resuscitation.

• Perform BLS protocols to open the airway, use a bag‐valve‐mask ventilatory device, and perform external chest compressions.

• Attach a defibrillator/pacer pads to the patient, and explain the operation of manual and automated defibrillators and external pacing systems.

• Maintain clinician safety with appropriate protective wear.

• Interpret cardiac rhythms and other diagnostic indicators.

• Synthesize diagnostic information to deliver medications and/or defibrillation, and perform procedures required during resuscitation efforts.

ATTITUDES

Hospitalists should be able to:

• Assess and respect the wishes of patients and families who desire no or limited resuscitation measures during hospitalization.

• Communicate with families to explain the efforts performed as well as outcomes and next steps.

• Rapidly respond to emergencies without distraction.

• Facilitate interactions between healthcare professionals about the roles that each will perform during the resuscitation effort.

• Review the resuscitation documentation for accuracy immediately following the event.

• Recognize the indications for emergent specialty consultation when available, which may include ENT, surgery, or critical care medicine.

• Appreciate the value of spiritual support services during and following resuscitation efforts.

• Discontinue resuscitation efforts when interventions have been unsuccessful and continued efforts are medically futile.

• Arrange for appropriate care transitions following successful resuscitation.

• Address family wishes regarding organ donation and autopsy.

ENDOTRACHEAL INTUBATION

KNOWLEDGE

Hospitalists should be able to:

• Describe the anatomy of the oral cavity, posterior pharynx and larynx.

• Describe clinical findings or disease processes that may require securing an airway.

• Describe the indications and contraindications, benefits and risks of endotracheal intubation.

• Describe the necessary equipment and medications required for routine and difficult intubations.

• Describe the process of endotracheal intubation from laryngoscope assembly to assessment of tube placement.

• Describe and differentiate alternatives to endotracheal intubation.

SKILLS

Hospitalists should be able to:

• Identify patients for whom endotracheal intubation may be required.

• Utilize bag‐valve‐mask ventilation with oral or nasal airway as a bridge to intubation.

• Select the appropriate laryngoscope blade for the individual patient.

• Position the patient and the bed for optimal procedure success and operator comfort.

• Assemble the laryngoscope and intubate the patient after visualizing the vocal cords.

• Prepare the oropharynx for intubation using necessary steps that may include removal of oral hardware, suctioning, and application of cricoid pressure.

• Request cricoid pressure and other maneuvers when indicated.

• Place the endotracheal tube at an appropriate depth in the airway.

• Confirm endotracheal tube placement by gastric and breath sounds, carbon dioxide monitor, and radiography; adjust tube position when indicated.

ATTITUDES

Hospitalists should be able to:

• Communicate with patients and families regarding procedure indications and next steps in management.

• Maintain high oxygen saturation prior to intubation whenever possible.

• Minimize patient trauma risk during intubations.

• Appreciate that bag‐valve‐mask can provide adequate oxygenation for extended periods when difficult intubations are delayed.

• Maintain clinician safety with appropriate protective wear.

• Use an alternative airway control device (e.g. laryngeal mask airway) for patients with difficult or unsuccessful intubations.

• Request appropriate specialist consultation for difficult or unsuccessful intubations or when clinician experience level precludes intubation trial.

MECHANICAL VENTILATION

KNOWLEDGE

Hospitalists should be able to:

• Describe the normal anatomy of the chest wall, thorax, and lung.

• Describe disease processes that lead to respiratory failure and expected clinical findings.

• Describe the indications, benefits and risks of mechanical ventilation.

• Describe indications and contraindications for non‐invasive ventilation in selected patients.

• Explain the role of arterial blood gas (ABG) analysis in the management of ventilated patients.

• Describe available modes of ventilation, and how to select initial and subsequent ventilator settings.

• Describe methods of and indications for sedation, comfort management, and/or paralysis in ventilated patients.

• Describe various ventilator settings and explain the use of individual settings based on the patient's disease process and clinical condition.

SKILLS

Hospitalists should be able to:

• Utilize nursing and respiratory therapy reports, physical examination, and ventilator data to identify complications due to mechanical ventilation.

• Select and adjust the ventilator mode and settings based on underlying disease process, other patient factors, ventilator data, and ABG analysis.

• Employ indicated interventions when complications of mechanical ventilation are identified.

• Identify the components of the ventilator, assess proper functioning, and identify equipment malfunction and/or patient‐ventilator dysynchrony.

• Order and interpret laboratory and imaging studies based on changes in patient's clinical status.

• Order adequate sedation and other indicated interventions to treat underlying conditions leading to respiratory failure and to prevent the complications of mechanical ventilation.

ATTITUDES

Hospitalists should be able to:

• Communicate with patients and/or families to explain the risks, benefits, and alternatives to invasive ventilation.

• Obtain informed consent prior to non‐emergent intubations.

• Conduct regular family meetings to provide clinical updates and facilitate shared decision‐making.

• Implement interventions shown to reduce risk of ventilator‐associated complications, which may include hospital acquired pneumonia, stress ulceration and bleeding, and venous thromboembolism.

• Provide adequate sedation, comfort management, and paralysis when indicated for patients requiring mechanical ventilation.

• Recognize the indications for specialty consultation, which may include critical care medicine.

SYSTEM ORGANIZATION AND IMPROVEMENT FOR EMERGENCY PROCEDURES

To improve efficiency and quality within their organizations, Hospitalists should:

• Collaborate with critical care physicians, respiratory therapists, and critical care nurses to develop evidence based protocols or guidelines for optimal ventilator management and weaning.

• Lead, coordinate or participate in evaluation of resuscitation and mechanical ventilation outcomes and identify and implement improvement initiatives.

• Lead, coordinate or participate in multidisciplinary teams, which may include critical care nurses, respiratory therapists, and critical care and emergency physicians, to establish ongoing training to ensure high quality performance of emergency procedures.

• Lead, coordinate or participate in multidisciplinary efforts to review antecedent events to identify changes in clinical status which, if promptly identified and acted upon, may have prevented the emergency intervention.

• Facilitate appropriate organization and consolidation of equipment in multiple identifiable and accessible locations in the hospital for performance of emergency procedures.

In Hospital Medicine, emergency procedures refer to advanced cardiac life support (ACLS), endotracheal intubation, and short‐term mechanical ventilation. Hospitalists care for patients admitted to the hospital with critical illnesses, as well as patients who have become critically ill during their hospital stay. In providing care to patients who have become critically ill, many Hospitalists perform or supervise these emergency procedures. Hospitalists lead efforts to provide timely, standardized response to inpatient emergencies.

CARDIOPULMONARY RESUSCITATION

KNOWLEDGE

Hospitalists should be able to:

• Describe the normal anatomy of the oral cavity, airway, thorax, heart and lungs.

• Describe the clinical findings or disease processes that require implementation of cardiopulmonary resuscitation and advanced life support.

• Describe clinical or cardiac rhythm findings that may impact outcomes for patients with cardiopulmonary arrest.

• List the laboratory and other diagnostic tests indicated during cardiopulmonary distress or arrest and immediately following successful resuscitation.

• Explain basic life support (BLS) protocols.

• Explain and differentiate current ACLS protocols, including the indicated interventions, based on the clinical situation and cardiac rhythm.

• Select the necessary equipment to manage the airway, identify cardiac rhythms, and perform defibrillation.

• Explain which cardiac rhythms and clinical situations require immediate defibrillation.

• Explain the mechanisms of action and uses of medications employed during ACLS.

• Explain the indications for procedural interventions that may be employed during the course of resuscitation.

• Explain the role of hyperthermia as a neuro‐protective measure in the post‐resuscitation period.

SKILLS

Hospitalists should be able to:

• Promptly identify acute cardiopulmonary distress or arrest, and call for assistance.

• Assess the patient, rapidly review the situation, and develop a differential diagnosis of etiology.

• Elicit additional history from the patient's family, other healthcare providers, and the patient's chart when available.

• Clearly and rapidly identify the event leader, and delineate other staff roles at the beginning of the resuscitation event.

• Properly position the patient on a backboard to perform BLS and ACLS protocols.

• Continually reassess proper patient positioning during resuscitation.

• Perform BLS protocols to open the airway, use a bag‐valve‐mask ventilatory device, and perform external chest compressions.

• Attach a defibrillator/pacer pads to the patient, and explain the operation of manual and automated defibrillators and external pacing systems.

• Maintain clinician safety with appropriate protective wear.

• Interpret cardiac rhythms and other diagnostic indicators.

• Synthesize diagnostic information to deliver medications and/or defibrillation, and perform procedures required during resuscitation efforts.

ATTITUDES

Hospitalists should be able to:

• Assess and respect the wishes of patients and families who desire no or limited resuscitation measures during hospitalization.

• Communicate with families to explain the efforts performed as well as outcomes and next steps.

• Rapidly respond to emergencies without distraction.

• Facilitate interactions between healthcare professionals about the roles that each will perform during the resuscitation effort.

• Review the resuscitation documentation for accuracy immediately following the event.

• Recognize the indications for emergent specialty consultation when available, which may include ENT, surgery, or critical care medicine.

• Appreciate the value of spiritual support services during and following resuscitation efforts.

• Discontinue resuscitation efforts when interventions have been unsuccessful and continued efforts are medically futile.

• Arrange for appropriate care transitions following successful resuscitation.

• Address family wishes regarding organ donation and autopsy.

ENDOTRACHEAL INTUBATION

KNOWLEDGE

Hospitalists should be able to:

• Describe the anatomy of the oral cavity, posterior pharynx and larynx.

• Describe clinical findings or disease processes that may require securing an airway.

• Describe the indications and contraindications, benefits and risks of endotracheal intubation.

• Describe the necessary equipment and medications required for routine and difficult intubations.

• Describe the process of endotracheal intubation from laryngoscope assembly to assessment of tube placement.

• Describe and differentiate alternatives to endotracheal intubation.

SKILLS

Hospitalists should be able to:

• Identify patients for whom endotracheal intubation may be required.

• Utilize bag‐valve‐mask ventilation with oral or nasal airway as a bridge to intubation.

• Select the appropriate laryngoscope blade for the individual patient.

• Position the patient and the bed for optimal procedure success and operator comfort.

• Assemble the laryngoscope and intubate the patient after visualizing the vocal cords.

• Prepare the oropharynx for intubation using necessary steps that may include removal of oral hardware, suctioning, and application of cricoid pressure.

• Request cricoid pressure and other maneuvers when indicated.

• Place the endotracheal tube at an appropriate depth in the airway.

• Confirm endotracheal tube placement by gastric and breath sounds, carbon dioxide monitor, and radiography; adjust tube position when indicated.

ATTITUDES

Hospitalists should be able to:

• Communicate with patients and families regarding procedure indications and next steps in management.

• Maintain high oxygen saturation prior to intubation whenever possible.

• Minimize patient trauma risk during intubations.

• Appreciate that bag‐valve‐mask can provide adequate oxygenation for extended periods when difficult intubations are delayed.

• Maintain clinician safety with appropriate protective wear.

• Use an alternative airway control device (e.g. laryngeal mask airway) for patients with difficult or unsuccessful intubations.

• Request appropriate specialist consultation for difficult or unsuccessful intubations or when clinician experience level precludes intubation trial.

MECHANICAL VENTILATION

KNOWLEDGE

Hospitalists should be able to:

• Describe the normal anatomy of the chest wall, thorax, and lung.

• Describe disease processes that lead to respiratory failure and expected clinical findings.

• Describe the indications, benefits and risks of mechanical ventilation.

• Describe indications and contraindications for non‐invasive ventilation in selected patients.

• Explain the role of arterial blood gas (ABG) analysis in the management of ventilated patients.

• Describe available modes of ventilation, and how to select initial and subsequent ventilator settings.

• Describe methods of and indications for sedation, comfort management, and/or paralysis in ventilated patients.

• Describe various ventilator settings and explain the use of individual settings based on the patient's disease process and clinical condition.

SKILLS

Hospitalists should be able to:

• Utilize nursing and respiratory therapy reports, physical examination, and ventilator data to identify complications due to mechanical ventilation.

• Select and adjust the ventilator mode and settings based on underlying disease process, other patient factors, ventilator data, and ABG analysis.

• Employ indicated interventions when complications of mechanical ventilation are identified.

• Identify the components of the ventilator, assess proper functioning, and identify equipment malfunction and/or patient‐ventilator dysynchrony.

• Order and interpret laboratory and imaging studies based on changes in patient's clinical status.

• Order adequate sedation and other indicated interventions to treat underlying conditions leading to respiratory failure and to prevent the complications of mechanical ventilation.

ATTITUDES

Hospitalists should be able to:

• Communicate with patients and/or families to explain the risks, benefits, and alternatives to invasive ventilation.

• Obtain informed consent prior to non‐emergent intubations.

• Conduct regular family meetings to provide clinical updates and facilitate shared decision‐making.

• Implement interventions shown to reduce risk of ventilator‐associated complications, which may include hospital acquired pneumonia, stress ulceration and bleeding, and venous thromboembolism.

• Provide adequate sedation, comfort management, and paralysis when indicated for patients requiring mechanical ventilation.

• Recognize the indications for specialty consultation, which may include critical care medicine.

SYSTEM ORGANIZATION AND IMPROVEMENT FOR EMERGENCY PROCEDURES

To improve efficiency and quality within their organizations, Hospitalists should:

• Collaborate with critical care physicians, respiratory therapists, and critical care nurses to develop evidence based protocols or guidelines for optimal ventilator management and weaning.

• Lead, coordinate or participate in evaluation of resuscitation and mechanical ventilation outcomes and identify and implement improvement initiatives.

• Lead, coordinate or participate in multidisciplinary teams, which may include critical care nurses, respiratory therapists, and critical care and emergency physicians, to establish ongoing training to ensure high quality performance of emergency procedures.

• Lead, coordinate or participate in multidisciplinary efforts to review antecedent events to identify changes in clinical status which, if promptly identified and acted upon, may have prevented the emergency intervention.

• Facilitate appropriate organization and consolidation of equipment in multiple identifiable and accessible locations in the hospital for performance of emergency procedures.

Healthcare‐associated infections impose a significant burden on the healthcare system in the Unites States, both economically and in terms of patient outcomes. The Centers for Disease Control and Prevention (CDC) estimate that nearly 2 million patients develop healthcare‐associated infections each year, and approximately 88,000 die as a direct or indirect result of their infections. These infections often lead to increases in length of hospitalization, and result in about $4.5 billion in excess costs annually. The central aim of infection control is to prevent healthcare‐associated infections and the emergence of resistant organisms. Hospitalists work in concert with other members of the healthcare organization to reduce healthcare‐associated infections, develop institutional initiatives for prevention, and promote and implement evidence based infection control measures.

KNOWLEDGE

Hospitalists should be able to:

• Describe acceptable methods of hand hygiene technique and timing in relationship to patient contact.

• Describe the prophylactic measures required for all types of isolation precautions, which include Standard, Contact, Droplet, and Airborne Precautions, and list the indications for implementing each type of precaution.

• List common types of healthcare‐associated infections, and describe the risk factors associated with urinary tract infections, surgical site infections, hospital‐acquired pneumonia, and blood stream infections.

• Explain the utility of the hospital antibiogram in delineating antimicrobial resistance patterns for bacterial isolates, and how it should be used to make empiric antibiotic selections.

• Identify major resources for infection control information, including hospital infection control staff, hospital infection control policies and procedures, local and state public health departments, and CDCP guidelines.

• Describe the indicated prevention measures necessary to perform hospital‐based procedures in a sterile fashion.

SKILLS

Hospitalists should be able to:

• Perform consistent and optimal hand hygiene techniques at all indicated points of care.

• Implement indicated isolation precautions for patients with high risk transmissible diseases or highly resistant infections.

• Identify and utilize local hospital resources, including antibiograms and infection control officers.

• Perform indicated infection control and prevention technique during all procedures.

• Implement precautions and infection control practices to protect patients from acquiring healthcare‐associated infections.

ATTITUDES

Hospitalists should be able to:

• Appreciate that specific infection control practices and engineering controls are required to protect very high risk patient populations, which may include hematopoietic stem cell transplant or solid organ transplant recipients, from healthcare associated infections.

• Serve as a role model in adherence to recommended hand hygiene and infection control practices.

• Communicate effectively the rationale and importance of infection control practices to patients, families, visitors, other health care providers and hospital staff.

• Communicate appropriate patient information to infection control staff regarding potentially transmissible diseases.

• Avoid devices that are more likely to cause hospital‐acquired infections if alternatives are safe, effective and available.

• Encourage removal of invasive devices, especially central venous catheters and urinary catheters, early during hospital stay and as soon as clinically safe to do so.

• Collaborate with multidisciplinary teams, which may include infection control, nursing service, and infectious disease consultants, to rapidly implement and maintain isolation precautions.

• Collaborate with multidisciplinary teams that may include infection control, nursing service, care coordination, long term care facilities, home health care staff, and public health personnel to plan for hospital discharge of patients with transmissible infectious diseases.

• Lead, coordinate or participate in efforts to educate other health care personnel and hospital staff about necessary infection control prevention measures.

• Lead, coordinate or participate in multidisciplinary teams that organize, implement, and study infection control protocols, guidelines or pathways, using evidence based systematic methods.

• Lead, coordinate or participate in multidisciplinary efforts to develop empiric antibiotic regimens to minimize the development of resistance within a particular hospital or region.

Healthcare‐associated infections impose a significant burden on the healthcare system in the Unites States, both economically and in terms of patient outcomes. The Centers for Disease Control and Prevention (CDC) estimate that nearly 2 million patients develop healthcare‐associated infections each year, and approximately 88,000 die as a direct or indirect result of their infections. These infections often lead to increases in length of hospitalization, and result in about $4.5 billion in excess costs annually. The central aim of infection control is to prevent healthcare‐associated infections and the emergence of resistant organisms. Hospitalists work in concert with other members of the healthcare organization to reduce healthcare‐associated infections, develop institutional initiatives for prevention, and promote and implement evidence based infection control measures.

KNOWLEDGE

Hospitalists should be able to:

• Describe acceptable methods of hand hygiene technique and timing in relationship to patient contact.

• Describe the prophylactic measures required for all types of isolation precautions, which include Standard, Contact, Droplet, and Airborne Precautions, and list the indications for implementing each type of precaution.

• List common types of healthcare‐associated infections, and describe the risk factors associated with urinary tract infections, surgical site infections, hospital‐acquired pneumonia, and blood stream infections.

• Explain the utility of the hospital antibiogram in delineating antimicrobial resistance patterns for bacterial isolates, and how it should be used to make empiric antibiotic selections.

• Identify major resources for infection control information, including hospital infection control staff, hospital infection control policies and procedures, local and state public health departments, and CDCP guidelines.

• Describe the indicated prevention measures necessary to perform hospital‐based procedures in a sterile fashion.

SKILLS

Hospitalists should be able to:

• Perform consistent and optimal hand hygiene techniques at all indicated points of care.

• Implement indicated isolation precautions for patients with high risk transmissible diseases or highly resistant infections.

• Identify and utilize local hospital resources, including antibiograms and infection control officers.

• Perform indicated infection control and prevention technique during all procedures.

• Implement precautions and infection control practices to protect patients from acquiring healthcare‐associated infections.

ATTITUDES

Hospitalists should be able to:

• Appreciate that specific infection control practices and engineering controls are required to protect very high risk patient populations, which may include hematopoietic stem cell transplant or solid organ transplant recipients, from healthcare associated infections.

• Serve as a role model in adherence to recommended hand hygiene and infection control practices.

• Communicate effectively the rationale and importance of infection control practices to patients, families, visitors, other health care providers and hospital staff.

• Communicate appropriate patient information to infection control staff regarding potentially transmissible diseases.

• Avoid devices that are more likely to cause hospital‐acquired infections if alternatives are safe, effective and available.

• Encourage removal of invasive devices, especially central venous catheters and urinary catheters, early during hospital stay and as soon as clinically safe to do so.

• Collaborate with multidisciplinary teams, which may include infection control, nursing service, and infectious disease consultants, to rapidly implement and maintain isolation precautions.

• Collaborate with multidisciplinary teams that may include infection control, nursing service, care coordination, long term care facilities, home health care staff, and public health personnel to plan for hospital discharge of patients with transmissible infectious diseases.

• Lead, coordinate or participate in efforts to educate other health care personnel and hospital staff about necessary infection control prevention measures.

• Lead, coordinate or participate in multidisciplinary teams that organize, implement, and study infection control protocols, guidelines or pathways, using evidence based systematic methods.

• Lead, coordinate or participate in multidisciplinary efforts to develop empiric antibiotic regimens to minimize the development of resistance within a particular hospital or region.

Healthcare‐associated infections impose a significant burden on the healthcare system in the Unites States, both economically and in terms of patient outcomes. The Centers for Disease Control and Prevention (CDC) estimate that nearly 2 million patients develop healthcare‐associated infections each year, and approximately 88,000 die as a direct or indirect result of their infections. These infections often lead to increases in length of hospitalization, and result in about $4.5 billion in excess costs annually. The central aim of infection control is to prevent healthcare‐associated infections and the emergence of resistant organisms. Hospitalists work in concert with other members of the healthcare organization to reduce healthcare‐associated infections, develop institutional initiatives for prevention, and promote and implement evidence based infection control measures.

KNOWLEDGE

Hospitalists should be able to:

• Describe acceptable methods of hand hygiene technique and timing in relationship to patient contact.

• Describe the prophylactic measures required for all types of isolation precautions, which include Standard, Contact, Droplet, and Airborne Precautions, and list the indications for implementing each type of precaution.

• List common types of healthcare‐associated infections, and describe the risk factors associated with urinary tract infections, surgical site infections, hospital‐acquired pneumonia, and blood stream infections.

• Explain the utility of the hospital antibiogram in delineating antimicrobial resistance patterns for bacterial isolates, and how it should be used to make empiric antibiotic selections.

• Identify major resources for infection control information, including hospital infection control staff, hospital infection control policies and procedures, local and state public health departments, and CDCP guidelines.

• Describe the indicated prevention measures necessary to perform hospital‐based procedures in a sterile fashion.

SKILLS

Hospitalists should be able to:

• Perform consistent and optimal hand hygiene techniques at all indicated points of care.

• Implement indicated isolation precautions for patients with high risk transmissible diseases or highly resistant infections.

• Identify and utilize local hospital resources, including antibiograms and infection control officers.

• Perform indicated infection control and prevention technique during all procedures.

• Implement precautions and infection control practices to protect patients from acquiring healthcare‐associated infections.

ATTITUDES

Hospitalists should be able to:

• Appreciate that specific infection control practices and engineering controls are required to protect very high risk patient populations, which may include hematopoietic stem cell transplant or solid organ transplant recipients, from healthcare associated infections.

• Serve as a role model in adherence to recommended hand hygiene and infection control practices.

• Communicate effectively the rationale and importance of infection control practices to patients, families, visitors, other health care providers and hospital staff.

• Communicate appropriate patient information to infection control staff regarding potentially transmissible diseases.

• Avoid devices that are more likely to cause hospital‐acquired infections if alternatives are safe, effective and available.

• Encourage removal of invasive devices, especially central venous catheters and urinary catheters, early during hospital stay and as soon as clinically safe to do so.

• Collaborate with multidisciplinary teams, which may include infection control, nursing service, and infectious disease consultants, to rapidly implement and maintain isolation precautions.

• Collaborate with multidisciplinary teams that may include infection control, nursing service, care coordination, long term care facilities, home health care staff, and public health personnel to plan for hospital discharge of patients with transmissible infectious diseases.

• Lead, coordinate or participate in efforts to educate other health care personnel and hospital staff about necessary infection control prevention measures.

• Lead, coordinate or participate in multidisciplinary teams that organize, implement, and study infection control protocols, guidelines or pathways, using evidence based systematic methods.

• Lead, coordinate or participate in multidisciplinary efforts to develop empiric antibiotic regimens to minimize the development of resistance within a particular hospital or region.

Diabetes mellitus is a disease characterized by abnormal insulin production or disordered glucose metabolism and is a co‐morbid condition of many hospitalized patients. diabetic ketoacidosis (dka) and hyperglycemia hyperosmolar state (hhs) are extreme presentations of diabetes mellitus that require hospitalization. there were 577,000 hospital discharges for diabetes mellitus in 2002, according to the american heart association. the prevalence of physician‐diagnosed diabetes mellitus was 13.9 million or 6.7 percent of the united states population. another 5.9 million americans are believed to have undiagnosed diabetes mellitus. the healthcare cost and utilization project (hcup) reports an average length‐of‐stay of 4.1 days and mean charges of $11,761 per patient for the diagnosis related group (drg) for diabetes mellitus. the estimated economic cost of diabetes in 2002 was $132 billion, of which $92 billion was direct medical costs. hospitalists care for diabetic patients and optimize glycemic control in the hospital setting. they stabilize and treat dka and hhs. the inpatient setting provides an opportunity to institute therapies to slow disease progression, prevent disease complications, and provide diabetic education to improve quality of life and limit complications leading to readmission. hospitalists use evidence based approaches to optimize care and lead multidisciplinary teams to develop institutional guidelines or care pathways to optimize glycemic control.

KNOWLEDGE

Hospitalists should be able to:

• Define diabetes mellitus and explain the pathophysiologic processes that can lead to hyperglycemia, dka and hhs.

• Describe the impact of hyperglycemia on immune function and wound healing.

• Describe the effect of dka and hhs on intravascular volume status, electrolytes and acid‐base balance.

• Describe the clinical presentation and laboratory findings of dka and hhs.

• Describe the indicated tests to evaluate and diagnose dka and hhs.

• Explain physiologic stressors and medications that adversely impact glycemic control.

• Explain the precipitating factors of dka and hss.

• Identify the goals of glycemic control in hospitalized patients in various settings, including critically ill and surgical patients, and cite supporting evidence.

• Explain indications, contraindications and mechanisms of action of pharmacologic agents used to treat diabetes mellitus.

• Explain the rationale of strict glycemic control and its effects on morbidity and mortality in hospitalized patients.

• Recognize factors that indicate severity of disease in patients with dka or hhs.

• Explain goals for hospital discharge, including specific measures of clinical stability for safe care transition.

SKILLS

Hospitalists should be able to:

• Elicit a thorough and relevant history, and review the medical record to identify symptoms suggestive of acute co‐morbid illness that can impact glycemic control.

• Estimate the level of outpatient glycemic control, adherence to medication regimen, and social influences that may impact glycemic control.

• Perform a comprehensive physical examination to identify possible precipitants of hyperglycemia, dka or hhs.

• Identify precipitating factors for dka and hhs, including infection, myocardial ischemia, and adherence to medication regimen.

• Select and interpret indicated studies in patients suspected of having dka or hhs, including electrolytes, beta‐hydroxybuterate, urinalysis, venous ph, and electrocardiogram.

• Recognize the indications for managing dka and hhs in an intensive care unit.

• Select appropriate insulin therapies, initiate fluid resuscitation, and manage the electrolyte disturbances caused by dka and hhs.

• Adjust medications to achieve optimal glycemic control and minimize side effects.

• Assess caloric and nutritional needs and order appropriate diabetic diet.

• Recognize and address neuropathic pain.

• Anticipate and manage the presence of ongoing metabolic derangements associated with dka and hhs.

• Develop an individualized diabetic regimen to achieve optimal glycemic control and prevent the development of complications from diabetes mellitus, including during the perioperative period.

ATTITUDES

Hospitalists should be able to:

• Communicate with patients and families to explain the history and prognosis of diabetes mellitus.

• Communicate with patients and families to explain potential long‐term complications of diabetes mellitus and prevention strategies, including foot and eye care.

• Communicate with patients and families to explain goals of care plan, discharge instructions and management after release from the hospital.

• Communicate with patients and families to explain the importance of and factors affecting glycemic control, such as adherence to medical regimens and self‐monitoring, following dietary and exercise recommendations, and complying with routine follow‐up appointments.

• Communicate with patients and families to explain the potential side effects or adverse interactions of diabetes medications, including hypoglycemia.

• Recognize indications for early specialty consultation, which may include endocrinology and nutrition.

• Employ a multidisciplinary approach, which may include nursing, nutrition and social services and a diabetes educator, to the care of patients with diabetes that begins at admission and continues through all care transitions.

• Document treatment plan and discharge instructions, and communicate with the outpatient clinician responsible for follow‐up, including the need for continued nutrition and diabetic counseling.

• Facilitate discharge planning early in the admission process.

• Recommend appropriate post‐discharge care, which may include endocrinology, ophthalmology, and podiatry.

• Utilize evidence based recommendation in the treatment of inpatients with diabetes mellitus.

SYSTEM ORGANIZATION AND IMPROVEMENT

To improve efficiency and quality within their organizations, hospitalists should:

• Implement systems to ensure hospital‐wide adherence to national standards (american diabetes association and others), and document those measures as specified by recognized organizations.

• Lead, coordinate or participate in efforts to develop guidelines and protocols that standardize assessment and aggressive treatment of dka and hhs.

• Lead, coordinate or participate in efforts to develop guidelines and/or protocols to optimize glycemic control in hospitalized patients, including intensive regimens in critically ill medical and surgical patients.

• Lead, coordinate or participate in multidisciplinary teams, which may include nursing, nutrition and endocrinology, to promote quality and cost‐effective diabetes management.

Diabetes mellitus is a disease characterized by abnormal insulin production or disordered glucose metabolism and is a co‐morbid condition of many hospitalized patients. diabetic ketoacidosis (dka) and hyperglycemia hyperosmolar state (hhs) are extreme presentations of diabetes mellitus that require hospitalization. there were 577,000 hospital discharges for diabetes mellitus in 2002, according to the american heart association. the prevalence of physician‐diagnosed diabetes mellitus was 13.9 million or 6.7 percent of the united states population. another 5.9 million americans are believed to have undiagnosed diabetes mellitus. the healthcare cost and utilization project (hcup) reports an average length‐of‐stay of 4.1 days and mean charges of $11,761 per patient for the diagnosis related group (drg) for diabetes mellitus. the estimated economic cost of diabetes in 2002 was $132 billion, of which $92 billion was direct medical costs. hospitalists care for diabetic patients and optimize glycemic control in the hospital setting. they stabilize and treat dka and hhs. the inpatient setting provides an opportunity to institute therapies to slow disease progression, prevent disease complications, and provide diabetic education to improve quality of life and limit complications leading to readmission. hospitalists use evidence based approaches to optimize care and lead multidisciplinary teams to develop institutional guidelines or care pathways to optimize glycemic control.

KNOWLEDGE

Hospitalists should be able to:

• Define diabetes mellitus and explain the pathophysiologic processes that can lead to hyperglycemia, dka and hhs.

• Describe the impact of hyperglycemia on immune function and wound healing.

• Describe the effect of dka and hhs on intravascular volume status, electrolytes and acid‐base balance.

• Describe the clinical presentation and laboratory findings of dka and hhs.

• Describe the indicated tests to evaluate and diagnose dka and hhs.

• Explain physiologic stressors and medications that adversely impact glycemic control.

• Explain the precipitating factors of dka and hss.

• Identify the goals of glycemic control in hospitalized patients in various settings, including critically ill and surgical patients, and cite supporting evidence.

• Explain indications, contraindications and mechanisms of action of pharmacologic agents used to treat diabetes mellitus.

• Explain the rationale of strict glycemic control and its effects on morbidity and mortality in hospitalized patients.

• Recognize factors that indicate severity of disease in patients with dka or hhs.

• Explain goals for hospital discharge, including specific measures of clinical stability for safe care transition.

SKILLS

Hospitalists should be able to:

• Elicit a thorough and relevant history, and review the medical record to identify symptoms suggestive of acute co‐morbid illness that can impact glycemic control.

• Estimate the level of outpatient glycemic control, adherence to medication regimen, and social influences that may impact glycemic control.

• Perform a comprehensive physical examination to identify possible precipitants of hyperglycemia, dka or hhs.

• Identify precipitating factors for dka and hhs, including infection, myocardial ischemia, and adherence to medication regimen.

• Select and interpret indicated studies in patients suspected of having dka or hhs, including electrolytes, beta‐hydroxybuterate, urinalysis, venous ph, and electrocardiogram.

• Recognize the indications for managing dka and hhs in an intensive care unit.

• Select appropriate insulin therapies, initiate fluid resuscitation, and manage the electrolyte disturbances caused by dka and hhs.

• Adjust medications to achieve optimal glycemic control and minimize side effects.

• Assess caloric and nutritional needs and order appropriate diabetic diet.

• Recognize and address neuropathic pain.

• Anticipate and manage the presence of ongoing metabolic derangements associated with dka and hhs.

• Develop an individualized diabetic regimen to achieve optimal glycemic control and prevent the development of complications from diabetes mellitus, including during the perioperative period.

ATTITUDES

Hospitalists should be able to:

• Communicate with patients and families to explain the history and prognosis of diabetes mellitus.

• Communicate with patients and families to explain potential long‐term complications of diabetes mellitus and prevention strategies, including foot and eye care.

• Communicate with patients and families to explain goals of care plan, discharge instructions and management after release from the hospital.

• Communicate with patients and families to explain the importance of and factors affecting glycemic control, such as adherence to medical regimens and self‐monitoring, following dietary and exercise recommendations, and complying with routine follow‐up appointments.

• Communicate with patients and families to explain the potential side effects or adverse interactions of diabetes medications, including hypoglycemia.

• Recognize indications for early specialty consultation, which may include endocrinology and nutrition.

• Employ a multidisciplinary approach, which may include nursing, nutrition and social services and a diabetes educator, to the care of patients with diabetes that begins at admission and continues through all care transitions.

• Document treatment plan and discharge instructions, and communicate with the outpatient clinician responsible for follow‐up, including the need for continued nutrition and diabetic counseling.

• Facilitate discharge planning early in the admission process.

• Recommend appropriate post‐discharge care, which may include endocrinology, ophthalmology, and podiatry.

• Utilize evidence based recommendation in the treatment of inpatients with diabetes mellitus.

SYSTEM ORGANIZATION AND IMPROVEMENT

To improve efficiency and quality within their organizations, hospitalists should:

• Implement systems to ensure hospital‐wide adherence to national standards (american diabetes association and others), and document those measures as specified by recognized organizations.

• Lead, coordinate or participate in efforts to develop guidelines and protocols that standardize assessment and aggressive treatment of dka and hhs.

• Lead, coordinate or participate in efforts to develop guidelines and/or protocols to optimize glycemic control in hospitalized patients, including intensive regimens in critically ill medical and surgical patients.

• Lead, coordinate or participate in multidisciplinary teams, which may include nursing, nutrition and endocrinology, to promote quality and cost‐effective diabetes management.

Diabetes mellitus is a disease characterized by abnormal insulin production or disordered glucose metabolism and is a co‐morbid condition of many hospitalized patients. diabetic ketoacidosis (dka) and hyperglycemia hyperosmolar state (hhs) are extreme presentations of diabetes mellitus that require hospitalization. there were 577,000 hospital discharges for diabetes mellitus in 2002, according to the american heart association. the prevalence of physician‐diagnosed diabetes mellitus was 13.9 million or 6.7 percent of the united states population. another 5.9 million americans are believed to have undiagnosed diabetes mellitus. the healthcare cost and utilization project (hcup) reports an average length‐of‐stay of 4.1 days and mean charges of $11,761 per patient for the diagnosis related group (drg) for diabetes mellitus. the estimated economic cost of diabetes in 2002 was $132 billion, of which $92 billion was direct medical costs. hospitalists care for diabetic patients and optimize glycemic control in the hospital setting. they stabilize and treat dka and hhs. the inpatient setting provides an opportunity to institute therapies to slow disease progression, prevent disease complications, and provide diabetic education to improve quality of life and limit complications leading to readmission. hospitalists use evidence based approaches to optimize care and lead multidisciplinary teams to develop institutional guidelines or care pathways to optimize glycemic control.

KNOWLEDGE

Hospitalists should be able to:

• Define diabetes mellitus and explain the pathophysiologic processes that can lead to hyperglycemia, dka and hhs.

• Describe the impact of hyperglycemia on immune function and wound healing.

• Describe the effect of dka and hhs on intravascular volume status, electrolytes and acid‐base balance.

• Describe the clinical presentation and laboratory findings of dka and hhs.

• Describe the indicated tests to evaluate and diagnose dka and hhs.

• Explain physiologic stressors and medications that adversely impact glycemic control.

• Explain the precipitating factors of dka and hss.

• Identify the goals of glycemic control in hospitalized patients in various settings, including critically ill and surgical patients, and cite supporting evidence.

• Explain indications, contraindications and mechanisms of action of pharmacologic agents used to treat diabetes mellitus.

• Explain the rationale of strict glycemic control and its effects on morbidity and mortality in hospitalized patients.

• Recognize factors that indicate severity of disease in patients with dka or hhs.

• Explain goals for hospital discharge, including specific measures of clinical stability for safe care transition.

SKILLS

Hospitalists should be able to:

• Elicit a thorough and relevant history, and review the medical record to identify symptoms suggestive of acute co‐morbid illness that can impact glycemic control.

• Estimate the level of outpatient glycemic control, adherence to medication regimen, and social influences that may impact glycemic control.

• Perform a comprehensive physical examination to identify possible precipitants of hyperglycemia, dka or hhs.

• Identify precipitating factors for dka and hhs, including infection, myocardial ischemia, and adherence to medication regimen.

• Select and interpret indicated studies in patients suspected of having dka or hhs, including electrolytes, beta‐hydroxybuterate, urinalysis, venous ph, and electrocardiogram.

• Recognize the indications for managing dka and hhs in an intensive care unit.

• Select appropriate insulin therapies, initiate fluid resuscitation, and manage the electrolyte disturbances caused by dka and hhs.

• Adjust medications to achieve optimal glycemic control and minimize side effects.

• Assess caloric and nutritional needs and order appropriate diabetic diet.

• Recognize and address neuropathic pain.

• Anticipate and manage the presence of ongoing metabolic derangements associated with dka and hhs.

• Develop an individualized diabetic regimen to achieve optimal glycemic control and prevent the development of complications from diabetes mellitus, including during the perioperative period.

ATTITUDES

Hospitalists should be able to:

• Communicate with patients and families to explain the history and prognosis of diabetes mellitus.

• Communicate with patients and families to explain potential long‐term complications of diabetes mellitus and prevention strategies, including foot and eye care.

• Communicate with patients and families to explain goals of care plan, discharge instructions and management after release from the hospital.

• Communicate with patients and families to explain the importance of and factors affecting glycemic control, such as adherence to medical regimens and self‐monitoring, following dietary and exercise recommendations, and complying with routine follow‐up appointments.

• Communicate with patients and families to explain the potential side effects or adverse interactions of diabetes medications, including hypoglycemia.

• Recognize indications for early specialty consultation, which may include endocrinology and nutrition.

• Employ a multidisciplinary approach, which may include nursing, nutrition and social services and a diabetes educator, to the care of patients with diabetes that begins at admission and continues through all care transitions.

• Document treatment plan and discharge instructions, and communicate with the outpatient clinician responsible for follow‐up, including the need for continued nutrition and diabetic counseling.

• Facilitate discharge planning early in the admission process.

• Recommend appropriate post‐discharge care, which may include endocrinology, ophthalmology, and podiatry.

• Utilize evidence based recommendation in the treatment of inpatients with diabetes mellitus.

SYSTEM ORGANIZATION AND IMPROVEMENT

To improve efficiency and quality within their organizations, hospitalists should:

• Implement systems to ensure hospital‐wide adherence to national standards (american diabetes association and others), and document those measures as specified by recognized organizations.

• Lead, coordinate or participate in efforts to develop guidelines and protocols that standardize assessment and aggressive treatment of dka and hhs.

• Lead, coordinate or participate in efforts to develop guidelines and/or protocols to optimize glycemic control in hospitalized patients, including intensive regimens in critically ill medical and surgical patients.

• Lead, coordinate or participate in multidisciplinary teams, which may include nursing, nutrition and endocrinology, to promote quality and cost‐effective diabetes management.