Background

Hospital Medicine is emerging as the next generation of the site‐defined specialties, following Emergency Medicine and Critical Care Medicine. The Society of Hospital Medicine estimates the need for 20,000‐30,000 practicing hospitalists in the next five to ten years. A variety of changes in healthcare delivery system and residency training programs has spurred this development. However, this growth has occurred in the absence of any standards of what knowledge, skills and attitudes a hospitalist must possess to successfully practice Hospital Medicine.

The publication of The Core Competencies in Hospital Medicine: A Framework for Curriculum Development by the Society of Hospital Medicine (The Core Competencies) represents the first attempt to define the specialty of Hospital Medicine. The Core Competencies culminates approximately four years of thoughtful research, planning, and development. The Core Competencies are a result of the contributions of over one hundred hospitalists and other content experts, under the guidance and leadership of the SHM Core Curriculum Task Force and Editorial Board. Task Force members were chosen from university and community hospitals, teaching and non‐teaching programs, for‐ and not‐for‐profit programs, and from all geographic regions of the United States to ensure broad representation of practicing hospitalists and SHM membership. A companion article to this supplement (Dressler DD, Pistoria MJ, Budnitz TL, McKean SCW, Amin AN. Core competencies in hospital medicine: development and methodology. J Hosp Med. 2006;1:48‐56) details the project methodology.

Purpose

The Core Competencies provide a framework for professional and curricular development based on a shared understanding of the essential knowledge, skills and attitudes expected of physicians working as hospitalists. The Core Competencies document specifically targets directors of continuing medical education (CME), Hospitalist programs and fellowships, residency programs, and medical school internal medicine clerkships. The goal is to standardize the expectations for training and professional development and to facilitate the development of curricula. The competencies were written to reflect learning outcomes, not convey specific content. They can be used to establish targets for learning outcomes. With these targets in mind, instructors can select content and instructional methods and shape the curricula based on the unique characteristics of the intended learners and learning context. A second companion article to the Core Competencies (McKean SCW, Budnitz TL, Dressler DD, Amin AN, Pistoria MJ. How to use The Core Competencies in Hospital Medicine: A Framework for Curriculum Development. J Hosp Med. 2006;1:57‐67) details how the competencies can be utilized to develop training and curricula to solve specific problems within an institution.

Organization Structure

The Core Competencies comprise three sectionsClinical Conditions, Procedures and Healthcare Systems. Within each section, individual chapters present competencies as three domains of educational outcomes: the Cognitive domain (Knowledge), the Psychomotor domain (Skills), and the Affective domain (Attitudes). The competencies have been carefully crafted as learning outcomes to indicate a specific, measurable level of proficiency that should be expected. Each chapter of the Clinical Conditions and Procedures sections also includes a Systems Organization and Improvement subsection. Outcome statements in this subsection possess attributes of each domain and indicate how the role of hospitalists should evolve. These outcome statements also acknowledge the current variance of responsibilities related to leading, coordinating or participating in the assessment, development or implementation of system improvements. More than any particular knowledge or skill, this systems approach distinguishes a hospitalist from other clinicians practicing in the hospital.

Conclusion

The educational strategy of the Society of Hospital Medicine was to stress the key concepts in hospital medicine in this first edition that would provide a framework for the development of timely, context‐specific training and curricula to meet the evolving needs of practicing hospitalists. Therefore, the Task Force selected to include the most commonly encountered clinical conditions, procedures, and healthcare systems that are central to the practice of Hospital Medicine today. We anticipate that future editions will build upon The Core Competencies with additional chapters and revisions to reflect feedback from its users, formal evaluation of its application and advances in the field of hospital medicine.

It is our goal that The Core Competencies in Hospital Medicine serve as a valuable resource. For the practicing hospitalist, it should aid the refinement of skills and assist in institutional program development. For residency program directors and clerkship directors, the chapters can function as a guide in curriculum development for inpatient medicine rotations or in meeting some of the Accreditation Council on Graduate Medical Education's Outcomes Project. Lastly, for those developing continuing medical education programs, The Core Competencies should serve as an outline around which educational programs can be developed.

The Core Curriculum Task Force Editorial Board

Michael J. Pistoria, DO, FACP (Chair)

Alpesh N. Amin, MD, MBA, FACP

Daniel D. Dressler, MD, MSc

Sylvia C. W. McKean, MD

Tina L. Budnitz, MPH

Background

Hospital Medicine is emerging as the next generation of the site‐defined specialties, following Emergency Medicine and Critical Care Medicine. The Society of Hospital Medicine estimates the need for 20,000‐30,000 practicing hospitalists in the next five to ten years. A variety of changes in healthcare delivery system and residency training programs has spurred this development. However, this growth has occurred in the absence of any standards of what knowledge, skills and attitudes a hospitalist must possess to successfully practice Hospital Medicine.

The publication of The Core Competencies in Hospital Medicine: A Framework for Curriculum Development by the Society of Hospital Medicine (The Core Competencies) represents the first attempt to define the specialty of Hospital Medicine. The Core Competencies culminates approximately four years of thoughtful research, planning, and development. The Core Competencies are a result of the contributions of over one hundred hospitalists and other content experts, under the guidance and leadership of the SHM Core Curriculum Task Force and Editorial Board. Task Force members were chosen from university and community hospitals, teaching and non‐teaching programs, for‐ and not‐for‐profit programs, and from all geographic regions of the United States to ensure broad representation of practicing hospitalists and SHM membership. A companion article to this supplement (Dressler DD, Pistoria MJ, Budnitz TL, McKean SCW, Amin AN. Core competencies in hospital medicine: development and methodology. J Hosp Med. 2006;1:48‐56) details the project methodology.

Purpose

The Core Competencies provide a framework for professional and curricular development based on a shared understanding of the essential knowledge, skills and attitudes expected of physicians working as hospitalists. The Core Competencies document specifically targets directors of continuing medical education (CME), Hospitalist programs and fellowships, residency programs, and medical school internal medicine clerkships. The goal is to standardize the expectations for training and professional development and to facilitate the development of curricula. The competencies were written to reflect learning outcomes, not convey specific content. They can be used to establish targets for learning outcomes. With these targets in mind, instructors can select content and instructional methods and shape the curricula based on the unique characteristics of the intended learners and learning context. A second companion article to the Core Competencies (McKean SCW, Budnitz TL, Dressler DD, Amin AN, Pistoria MJ. How to use The Core Competencies in Hospital Medicine: A Framework for Curriculum Development. J Hosp Med. 2006;1:57‐67) details how the competencies can be utilized to develop training and curricula to solve specific problems within an institution.

Organization Structure

The Core Competencies comprise three sectionsClinical Conditions, Procedures and Healthcare Systems. Within each section, individual chapters present competencies as three domains of educational outcomes: the Cognitive domain (Knowledge), the Psychomotor domain (Skills), and the Affective domain (Attitudes). The competencies have been carefully crafted as learning outcomes to indicate a specific, measurable level of proficiency that should be expected. Each chapter of the Clinical Conditions and Procedures sections also includes a Systems Organization and Improvement subsection. Outcome statements in this subsection possess attributes of each domain and indicate how the role of hospitalists should evolve. These outcome statements also acknowledge the current variance of responsibilities related to leading, coordinating or participating in the assessment, development or implementation of system improvements. More than any particular knowledge or skill, this systems approach distinguishes a hospitalist from other clinicians practicing in the hospital.

Conclusion

The educational strategy of the Society of Hospital Medicine was to stress the key concepts in hospital medicine in this first edition that would provide a framework for the development of timely, context‐specific training and curricula to meet the evolving needs of practicing hospitalists. Therefore, the Task Force selected to include the most commonly encountered clinical conditions, procedures, and healthcare systems that are central to the practice of Hospital Medicine today. We anticipate that future editions will build upon The Core Competencies with additional chapters and revisions to reflect feedback from its users, formal evaluation of its application and advances in the field of hospital medicine.

It is our goal that The Core Competencies in Hospital Medicine serve as a valuable resource. For the practicing hospitalist, it should aid the refinement of skills and assist in institutional program development. For residency program directors and clerkship directors, the chapters can function as a guide in curriculum development for inpatient medicine rotations or in meeting some of the Accreditation Council on Graduate Medical Education's Outcomes Project. Lastly, for those developing continuing medical education programs, The Core Competencies should serve as an outline around which educational programs can be developed.

The Core Curriculum Task Force Editorial Board

Michael J. Pistoria, DO, FACP (Chair)

Alpesh N. Amin, MD, MBA, FACP

Daniel D. Dressler, MD, MSc

Sylvia C. W. McKean, MD

Tina L. Budnitz, MPH

Background

Hospital Medicine is emerging as the next generation of the site‐defined specialties, following Emergency Medicine and Critical Care Medicine. The Society of Hospital Medicine estimates the need for 20,000‐30,000 practicing hospitalists in the next five to ten years. A variety of changes in healthcare delivery system and residency training programs has spurred this development. However, this growth has occurred in the absence of any standards of what knowledge, skills and attitudes a hospitalist must possess to successfully practice Hospital Medicine.

The publication of The Core Competencies in Hospital Medicine: A Framework for Curriculum Development by the Society of Hospital Medicine (The Core Competencies) represents the first attempt to define the specialty of Hospital Medicine. The Core Competencies culminates approximately four years of thoughtful research, planning, and development. The Core Competencies are a result of the contributions of over one hundred hospitalists and other content experts, under the guidance and leadership of the SHM Core Curriculum Task Force and Editorial Board. Task Force members were chosen from university and community hospitals, teaching and non‐teaching programs, for‐ and not‐for‐profit programs, and from all geographic regions of the United States to ensure broad representation of practicing hospitalists and SHM membership. A companion article to this supplement (Dressler DD, Pistoria MJ, Budnitz TL, McKean SCW, Amin AN. Core competencies in hospital medicine: development and methodology. J Hosp Med. 2006;1:48‐56) details the project methodology.

Purpose

The Core Competencies provide a framework for professional and curricular development based on a shared understanding of the essential knowledge, skills and attitudes expected of physicians working as hospitalists. The Core Competencies document specifically targets directors of continuing medical education (CME), Hospitalist programs and fellowships, residency programs, and medical school internal medicine clerkships. The goal is to standardize the expectations for training and professional development and to facilitate the development of curricula. The competencies were written to reflect learning outcomes, not convey specific content. They can be used to establish targets for learning outcomes. With these targets in mind, instructors can select content and instructional methods and shape the curricula based on the unique characteristics of the intended learners and learning context. A second companion article to the Core Competencies (McKean SCW, Budnitz TL, Dressler DD, Amin AN, Pistoria MJ. How to use The Core Competencies in Hospital Medicine: A Framework for Curriculum Development. J Hosp Med. 2006;1:57‐67) details how the competencies can be utilized to develop training and curricula to solve specific problems within an institution.

Organization Structure

The Core Competencies comprise three sectionsClinical Conditions, Procedures and Healthcare Systems. Within each section, individual chapters present competencies as three domains of educational outcomes: the Cognitive domain (Knowledge), the Psychomotor domain (Skills), and the Affective domain (Attitudes). The competencies have been carefully crafted as learning outcomes to indicate a specific, measurable level of proficiency that should be expected. Each chapter of the Clinical Conditions and Procedures sections also includes a Systems Organization and Improvement subsection. Outcome statements in this subsection possess attributes of each domain and indicate how the role of hospitalists should evolve. These outcome statements also acknowledge the current variance of responsibilities related to leading, coordinating or participating in the assessment, development or implementation of system improvements. More than any particular knowledge or skill, this systems approach distinguishes a hospitalist from other clinicians practicing in the hospital.

Conclusion

The educational strategy of the Society of Hospital Medicine was to stress the key concepts in hospital medicine in this first edition that would provide a framework for the development of timely, context‐specific training and curricula to meet the evolving needs of practicing hospitalists. Therefore, the Task Force selected to include the most commonly encountered clinical conditions, procedures, and healthcare systems that are central to the practice of Hospital Medicine today. We anticipate that future editions will build upon The Core Competencies with additional chapters and revisions to reflect feedback from its users, formal evaluation of its application and advances in the field of hospital medicine.

It is our goal that The Core Competencies in Hospital Medicine serve as a valuable resource. For the practicing hospitalist, it should aid the refinement of skills and assist in institutional program development. For residency program directors and clerkship directors, the chapters can function as a guide in curriculum development for inpatient medicine rotations or in meeting some of the Accreditation Council on Graduate Medical Education's Outcomes Project. Lastly, for those developing continuing medical education programs, The Core Competencies should serve as an outline around which educational programs can be developed.

The Core Curriculum Task Force Editorial Board

Michael J. Pistoria, DO, FACP (Chair)

Alpesh N. Amin, MD, MBA, FACP

Daniel D. Dressler, MD, MSc

Sylvia C. W. McKean, MD

Tina L. Budnitz, MPH

Vulnerable populations are defined as groups who are at increased risk of receiving a disparity in medical care on the basis of financial circumstances or social characteristics such as age, race, gender, ethnicity, sexual orientation, spirituality, disability, or socioeconomic or insurance status. Hospitalists may play a significant role in influencing the health status, health care access, and health care delivery to vulnerable populations due to their higher rates of hospital utilization and lower access to outpatient care. Agency for Healthcare Research and Quality (AHRQ) estimates health expenditures due to low health literacy range from $29 billion to $69 billion per year. Death rates per 1,000 admissions in low mortality Diagnosis Related Groups (DRG) are higher for hispanics (0.65), blacks (0.71) and the uninsured (1.1) compared to whites (0.61) and the privately insured (0.61). The Nationwide Inpatient Sample (NIS) benchmark mortality in low mortality DRGs is less than 0.5%. Hospitalists may serve as initial points of contact for the health care of these groups. Core competencies in communication, advocacy and comprehension of the health care needs of vulnerable populations may influence healthcare expenditures, morbidity and mortality. Hospitalists can lead initiatives that promote equity of healthcare provision.

KNOWLEDGE

Hospitalists should be able to:

• Explain key factors leading to disparities in health status among specific vulnerable populations.

• Explain disease processes that disproportionately affect vulnerable populations.

• Describe key factors leading to disparities in the quality of care provided to vulnerable groups.

• List services in local healthcare system designed to ameliorate barriers to care provision.

• Name local and institutional resources available to patients needing financial assistance.

• Identify key elements of discharge planning for uninsured, underinsured, and disabled patients.

SKILLS

Hospitalists should be able to:

• Elicit elements of the history and physical examination to detect illnesses for which vulnerable populations may have increased risk.

• Elicit a social history to assess patient habits, identify patients at risk for breaks in transitions of care, and clarify patient values around treatment options.

• Tailor the therapeutic plan that takes into account discharge plan and outpatient resources.

• Identify vulnerable patients whose outpatient environment might benefit from additional community resources.

• Target vulnerable groups for indicated vaccinations and preventive care services or referrals.

ATTITUDES

Hospitalists should be able to:

• Utilize appropriate educational resources to inform vulnerable patients with low health literacy.

• Provide education and systems interventions to minimize medication errors in patients with low health literacy.

• Communicate openly to facilitate trust in patient‐physician interactions.

• Actively involve patients and families in the design of care plans.

• Secure translators to assist with interviewing, physical examination, and medical decision making.

• Facilitate communication between vulnerable patient groups and consultants.

• Provide leadership to foster attitudes and systems improvements that promote quality health care provision to vulnerable populations.

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

• Coordinate adequate transitions of care from the inpatient to outpatient setting.

• Communicate with primary care physicians to facilitate transitions of care.

Vulnerable populations are defined as groups who are at increased risk of receiving a disparity in medical care on the basis of financial circumstances or social characteristics such as age, race, gender, ethnicity, sexual orientation, spirituality, disability, or socioeconomic or insurance status. Hospitalists may play a significant role in influencing the health status, health care access, and health care delivery to vulnerable populations due to their higher rates of hospital utilization and lower access to outpatient care. Agency for Healthcare Research and Quality (AHRQ) estimates health expenditures due to low health literacy range from $29 billion to $69 billion per year. Death rates per 1,000 admissions in low mortality Diagnosis Related Groups (DRG) are higher for hispanics (0.65), blacks (0.71) and the uninsured (1.1) compared to whites (0.61) and the privately insured (0.61). The Nationwide Inpatient Sample (NIS) benchmark mortality in low mortality DRGs is less than 0.5%. Hospitalists may serve as initial points of contact for the health care of these groups. Core competencies in communication, advocacy and comprehension of the health care needs of vulnerable populations may influence healthcare expenditures, morbidity and mortality. Hospitalists can lead initiatives that promote equity of healthcare provision.

KNOWLEDGE

Hospitalists should be able to:

• Explain key factors leading to disparities in health status among specific vulnerable populations.

• Explain disease processes that disproportionately affect vulnerable populations.

• Describe key factors leading to disparities in the quality of care provided to vulnerable groups.

• List services in local healthcare system designed to ameliorate barriers to care provision.

• Name local and institutional resources available to patients needing financial assistance.

• Identify key elements of discharge planning for uninsured, underinsured, and disabled patients.

SKILLS

Hospitalists should be able to:

• Elicit elements of the history and physical examination to detect illnesses for which vulnerable populations may have increased risk.

• Elicit a social history to assess patient habits, identify patients at risk for breaks in transitions of care, and clarify patient values around treatment options.

• Tailor the therapeutic plan that takes into account discharge plan and outpatient resources.

• Identify vulnerable patients whose outpatient environment might benefit from additional community resources.

• Target vulnerable groups for indicated vaccinations and preventive care services or referrals.

ATTITUDES

Hospitalists should be able to:

• Utilize appropriate educational resources to inform vulnerable patients with low health literacy.

• Provide education and systems interventions to minimize medication errors in patients with low health literacy.

• Communicate openly to facilitate trust in patient‐physician interactions.

• Actively involve patients and families in the design of care plans.

• Secure translators to assist with interviewing, physical examination, and medical decision making.

• Facilitate communication between vulnerable patient groups and consultants.

• Provide leadership to foster attitudes and systems improvements that promote quality health care provision to vulnerable populations.

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

• Coordinate adequate transitions of care from the inpatient to outpatient setting.

• Communicate with primary care physicians to facilitate transitions of care.

Vulnerable populations are defined as groups who are at increased risk of receiving a disparity in medical care on the basis of financial circumstances or social characteristics such as age, race, gender, ethnicity, sexual orientation, spirituality, disability, or socioeconomic or insurance status. Hospitalists may play a significant role in influencing the health status, health care access, and health care delivery to vulnerable populations due to their higher rates of hospital utilization and lower access to outpatient care. Agency for Healthcare Research and Quality (AHRQ) estimates health expenditures due to low health literacy range from $29 billion to $69 billion per year. Death rates per 1,000 admissions in low mortality Diagnosis Related Groups (DRG) are higher for hispanics (0.65), blacks (0.71) and the uninsured (1.1) compared to whites (0.61) and the privately insured (0.61). The Nationwide Inpatient Sample (NIS) benchmark mortality in low mortality DRGs is less than 0.5%. Hospitalists may serve as initial points of contact for the health care of these groups. Core competencies in communication, advocacy and comprehension of the health care needs of vulnerable populations may influence healthcare expenditures, morbidity and mortality. Hospitalists can lead initiatives that promote equity of healthcare provision.

KNOWLEDGE

Hospitalists should be able to:

• Explain key factors leading to disparities in health status among specific vulnerable populations.

• Explain disease processes that disproportionately affect vulnerable populations.

• Describe key factors leading to disparities in the quality of care provided to vulnerable groups.

• List services in local healthcare system designed to ameliorate barriers to care provision.

• Name local and institutional resources available to patients needing financial assistance.

• Identify key elements of discharge planning for uninsured, underinsured, and disabled patients.

SKILLS

Hospitalists should be able to:

• Elicit elements of the history and physical examination to detect illnesses for which vulnerable populations may have increased risk.

• Elicit a social history to assess patient habits, identify patients at risk for breaks in transitions of care, and clarify patient values around treatment options.

• Tailor the therapeutic plan that takes into account discharge plan and outpatient resources.

• Identify vulnerable patients whose outpatient environment might benefit from additional community resources.

• Target vulnerable groups for indicated vaccinations and preventive care services or referrals.

ATTITUDES

Hospitalists should be able to:

• Utilize appropriate educational resources to inform vulnerable patients with low health literacy.

• Provide education and systems interventions to minimize medication errors in patients with low health literacy.

• Communicate openly to facilitate trust in patient‐physician interactions.

• Actively involve patients and families in the design of care plans.

• Secure translators to assist with interviewing, physical examination, and medical decision making.

• Facilitate communication between vulnerable patient groups and consultants.

• Provide leadership to foster attitudes and systems improvements that promote quality health care provision to vulnerable populations.

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

• Coordinate adequate transitions of care from the inpatient to outpatient setting.

• Communicate with primary care physicians to facilitate transitions of care.

Asthma involves bronchospasm with reversible airflow limitation and an abnormal airway inflammatory response. The Healthcare Cost and Utilization Project (HCUP) estimates 130,000 hospital discharges for asthma in 2002. The mean length‐of‐stay was 2.8 days, with mean charges of $8,000 per patient. When viewed as part of the Diagnosis Related Group (DRG) for Chronic Obstructive Pulmonary Disease, the data is slightly different. These patients accounted for 85,000 discharges with mean charges of almost $14,000 per patient. The mean length‐of‐stay was 4.6 days in this group, with an in‐hospital mortality of 0.6%. Hospitalists use evidence based approaches to optimize care of patients with asthma exacerbation. Hospitalists lead multidisciplinary teams to develop institutional guidelines or care pathways to improve efficiency and quality of care and to reduce readmission rates.

KNOWLEDGE

Hospitalists should be able to:

• Define asthma and describe the pathophysiologic processes that lead to reversible airway obstruction and inflammation.

• Identify precipitants of asthma exacerbation.

• Recognize and differentiate the clinical presentation of asthma exacerbation from other acute respiratory and non‐respiratory syndromes.

• Describe the role of diagnostic testing, including peak flow monitoring, used for evaluation of asthma exacerbation.

• Describe evidence based therapies for the treatment of asthma exacerbations, which may include bronchodilators, systemic corticosteroids, and oxygen.

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

• Explain the indications for invasive ventilatory support.

• List the risk factors for disease severity and death from asthma.

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

SKILLS

Hospitalists should be able to:

• Elicit a focused history to identify triggers of asthma and symptoms consistent with asthma exacerbation.

• Perform a targeted physical examination to elicit signs consistent with asthma exacerbation, differentiate findings from other mimicking conditions, and assess severity of illness.

• Select and interpret appropriate diagnostic studies to evaluate severity of asthma exacerbation.

• Recognize impending respiratory failure and coordinate intubation when indicated.

• Prescribe appropriate evidence based pharmacologic therapies during asthma exacerbation, using the most appropriate route, dose, frequency and duration of treatment.

ATTITUDES

Hospitalists should be able to:

• Communicate with patients and families to explain the natural history and prognosis of asthma.

• Communicate with patients and families to explain the goals of care plan, including clinical stability criteria, the importance of prevention measures such as smoking cessation and modification of environmental exposures, and required follow‐up care.

• Communicate with patients and families to explain discharge medications, potential side effects, duration of therapy and dosing, and taper schedule.

• Ensure that prior to discharge, patients receive training of proper inhaler and peak flow techniques.

• Differentiate for patients and families the indications and appropriate use of daily use inhalers and rescue inhalers for asthmatic control.

• Communicate with patients and families to explain symptoms and signs that should prompt emergent medical management.

• Recognize indications for specialty consultation, including pulmonary and allergy medicine.

• Promote prevention strategies including smoking cessation and indicated vaccinations.

• Employ a multidisciplinary approach, which may include pulmonary medicine, respiratory therapy, nursing and social services, to the care of patients with asthma exacerbation.

• Collaborate with primary care physicians and emergency physicians in making the admission decision.

• Document treatment plan and discharge instructions, and communicate with the outpatient clinician responsible for follow‐up.

• Provide and coordinate resources for patients to ensure safe transition from the hospital to arranged follow‐up care.

• Utilize evidence based recommendations for the treatment of patients with asthma exacerbations.

SYSTEM ORGANIZATION AND IMPROVEMENT

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

• Develop educational modules, order sets, and/or pathways that facilitate use of evidence based strategies for asthma exacerbation in the emergency department and the hospital, with goals of improving outcomes, decreasing length of stay, and reducing re‐hospitalization rates.

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

• Lead, coordinate or participate in multidisciplinary initiatives, which may include collaborative efforts with pulmonologists, to promote patient safety and optimize cost‐effective diagnostic and management strategies for patients with asthma.

Asthma involves bronchospasm with reversible airflow limitation and an abnormal airway inflammatory response. The Healthcare Cost and Utilization Project (HCUP) estimates 130,000 hospital discharges for asthma in 2002. The mean length‐of‐stay was 2.8 days, with mean charges of $8,000 per patient. When viewed as part of the Diagnosis Related Group (DRG) for Chronic Obstructive Pulmonary Disease, the data is slightly different. These patients accounted for 85,000 discharges with mean charges of almost $14,000 per patient. The mean length‐of‐stay was 4.6 days in this group, with an in‐hospital mortality of 0.6%. Hospitalists use evidence based approaches to optimize care of patients with asthma exacerbation. Hospitalists lead multidisciplinary teams to develop institutional guidelines or care pathways to improve efficiency and quality of care and to reduce readmission rates.

KNOWLEDGE

Hospitalists should be able to:

• Define asthma and describe the pathophysiologic processes that lead to reversible airway obstruction and inflammation.

• Identify precipitants of asthma exacerbation.

• Recognize and differentiate the clinical presentation of asthma exacerbation from other acute respiratory and non‐respiratory syndromes.

• Describe the role of diagnostic testing, including peak flow monitoring, used for evaluation of asthma exacerbation.

• Describe evidence based therapies for the treatment of asthma exacerbations, which may include bronchodilators, systemic corticosteroids, and oxygen.

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

• Explain the indications for invasive ventilatory support.

• List the risk factors for disease severity and death from asthma.

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

SKILLS

Hospitalists should be able to:

• Elicit a focused history to identify triggers of asthma and symptoms consistent with asthma exacerbation.

• Perform a targeted physical examination to elicit signs consistent with asthma exacerbation, differentiate findings from other mimicking conditions, and assess severity of illness.

• Select and interpret appropriate diagnostic studies to evaluate severity of asthma exacerbation.

• Recognize impending respiratory failure and coordinate intubation when indicated.

• Prescribe appropriate evidence based pharmacologic therapies during asthma exacerbation, using the most appropriate route, dose, frequency and duration of treatment.

ATTITUDES

Hospitalists should be able to:

• Communicate with patients and families to explain the natural history and prognosis of asthma.

• Communicate with patients and families to explain the goals of care plan, including clinical stability criteria, the importance of prevention measures such as smoking cessation and modification of environmental exposures, and required follow‐up care.

• Communicate with patients and families to explain discharge medications, potential side effects, duration of therapy and dosing, and taper schedule.

• Ensure that prior to discharge, patients receive training of proper inhaler and peak flow techniques.

• Differentiate for patients and families the indications and appropriate use of daily use inhalers and rescue inhalers for asthmatic control.

• Communicate with patients and families to explain symptoms and signs that should prompt emergent medical management.

• Recognize indications for specialty consultation, including pulmonary and allergy medicine.

• Promote prevention strategies including smoking cessation and indicated vaccinations.

• Employ a multidisciplinary approach, which may include pulmonary medicine, respiratory therapy, nursing and social services, to the care of patients with asthma exacerbation.

• Collaborate with primary care physicians and emergency physicians in making the admission decision.

• Document treatment plan and discharge instructions, and communicate with the outpatient clinician responsible for follow‐up.

• Provide and coordinate resources for patients to ensure safe transition from the hospital to arranged follow‐up care.

• Utilize evidence based recommendations for the treatment of patients with asthma exacerbations.

SYSTEM ORGANIZATION AND IMPROVEMENT

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

• Develop educational modules, order sets, and/or pathways that facilitate use of evidence based strategies for asthma exacerbation in the emergency department and the hospital, with goals of improving outcomes, decreasing length of stay, and reducing re‐hospitalization rates.

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

• Lead, coordinate or participate in multidisciplinary initiatives, which may include collaborative efforts with pulmonologists, to promote patient safety and optimize cost‐effective diagnostic and management strategies for patients with asthma.

Asthma involves bronchospasm with reversible airflow limitation and an abnormal airway inflammatory response. The Healthcare Cost and Utilization Project (HCUP) estimates 130,000 hospital discharges for asthma in 2002. The mean length‐of‐stay was 2.8 days, with mean charges of $8,000 per patient. When viewed as part of the Diagnosis Related Group (DRG) for Chronic Obstructive Pulmonary Disease, the data is slightly different. These patients accounted for 85,000 discharges with mean charges of almost $14,000 per patient. The mean length‐of‐stay was 4.6 days in this group, with an in‐hospital mortality of 0.6%. Hospitalists use evidence based approaches to optimize care of patients with asthma exacerbation. Hospitalists lead multidisciplinary teams to develop institutional guidelines or care pathways to improve efficiency and quality of care and to reduce readmission rates.

KNOWLEDGE

Hospitalists should be able to:

• Define asthma and describe the pathophysiologic processes that lead to reversible airway obstruction and inflammation.

• Identify precipitants of asthma exacerbation.

• Recognize and differentiate the clinical presentation of asthma exacerbation from other acute respiratory and non‐respiratory syndromes.

• Describe the role of diagnostic testing, including peak flow monitoring, used for evaluation of asthma exacerbation.

• Describe evidence based therapies for the treatment of asthma exacerbations, which may include bronchodilators, systemic corticosteroids, and oxygen.

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

• Explain the indications for invasive ventilatory support.

• List the risk factors for disease severity and death from asthma.

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

SKILLS

Hospitalists should be able to:

• Elicit a focused history to identify triggers of asthma and symptoms consistent with asthma exacerbation.

• Perform a targeted physical examination to elicit signs consistent with asthma exacerbation, differentiate findings from other mimicking conditions, and assess severity of illness.

• Select and interpret appropriate diagnostic studies to evaluate severity of asthma exacerbation.

• Recognize impending respiratory failure and coordinate intubation when indicated.

• Prescribe appropriate evidence based pharmacologic therapies during asthma exacerbation, using the most appropriate route, dose, frequency and duration of treatment.

ATTITUDES

Hospitalists should be able to:

• Communicate with patients and families to explain the natural history and prognosis of asthma.

• Communicate with patients and families to explain the goals of care plan, including clinical stability criteria, the importance of prevention measures such as smoking cessation and modification of environmental exposures, and required follow‐up care.

• Communicate with patients and families to explain discharge medications, potential side effects, duration of therapy and dosing, and taper schedule.

• Ensure that prior to discharge, patients receive training of proper inhaler and peak flow techniques.

• Differentiate for patients and families the indications and appropriate use of daily use inhalers and rescue inhalers for asthmatic control.

• Communicate with patients and families to explain symptoms and signs that should prompt emergent medical management.

• Recognize indications for specialty consultation, including pulmonary and allergy medicine.

• Promote prevention strategies including smoking cessation and indicated vaccinations.

• Employ a multidisciplinary approach, which may include pulmonary medicine, respiratory therapy, nursing and social services, to the care of patients with asthma exacerbation.

• Collaborate with primary care physicians and emergency physicians in making the admission decision.

• Document treatment plan and discharge instructions, and communicate with the outpatient clinician responsible for follow‐up.

• Provide and coordinate resources for patients to ensure safe transition from the hospital to arranged follow‐up care.

• Utilize evidence based recommendations for the treatment of patients with asthma exacerbations.

SYSTEM ORGANIZATION AND IMPROVEMENT

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

• Develop educational modules, order sets, and/or pathways that facilitate use of evidence based strategies for asthma exacerbation in the emergency department and the hospital, with goals of improving outcomes, decreasing length of stay, and reducing re‐hospitalization rates.

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

• Lead, coordinate or participate in multidisciplinary initiatives, which may include collaborative efforts with pulmonologists, to promote patient safety and optimize cost‐effective diagnostic and management strategies for patients with asthma.

Acute renal failure (ARF) is defined as a decline in renal function over a period of hours or days, which results in an inability to maintain electrolyte homeostasis and an accumulation of nitrogenous waste products. ARF can be a presenting manifestation of a serious illness requiring hospitalization, or occur as a complication of illness or treatment in a hospitalized patient. the healthcare cost and utilization project (HCUP) estimates 141,000 discharges for ARF in 2002, with mean charges of almost $22,000 per patient. the mean length of stay was 6.7 days for these patients, with an in‐hospital mortality of 10.3%. hospitalists can advocate and initiate prevention strategies to reduce the incidence of ARF. hospitalists may also facilitate expeditious evaluation and management of ARF to improve patient outcomes, optimize resource utilization and reduce length of stay.

KNOWLEDGE

Hospitalists should be able to:

• Define the clinical significance of pre‐renal failure, intrinsic renal disease, and post‐renal failure.

• Describe the symptoms and signs of pre‐renal failure, intrinsic renal failure, and post‐renal failure.

• Distinguish the causes of pre‐renal failure, intrinsic renal failure, and post‐renal failure.

• Identify common electrolyte abnormalities that occur with acute renal failure, and institute corrective therapy.

• Describe the indicated tests required to evaluate ARF.

• Calculate estimated creatinine clearance for adjustment of medication dosage when indicated.

• Identify patients at risk for ARF and institute preventive measures, which may include intravenous fluid and acetylcysteine in patients receiving radiocontrast media.

• Identify hospitalized patients at risk for ARF and institute preventive measures.

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

• Describe indications for acute hemodialysis.

• Identify clinical, laboratory and imaging studies that indicate severity of disease.

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

SKILLS

Hospitalists should be able to:

• Elicit a thorough and relevant history and review the medical record for factors predisposing or contributing to the development of ARF.

• Review all drug use including prescription and over‐the‐counter medications, herbal remedies, nutritional supplements, and illicit drugs.

• Perform a physical examination to assess volume status and to identify underlying co‐morbid states that may result in ARF.

• Order and interpret indicated diagnostic studies that may include urinalysis and microscopic sediment analysis, urinary diagnostic indices, urinary protein excretion, serologic evaluation, and renal imaging.

• Avoid use of radiographic contrast agents and order non‐ionic agents when available.

• Identify patients who may benefit from early hemodialysis.

• Determine or coordinate appropriate nutritional and metabolic interventions.

• Formulate a treatment plan tailored to the individual patient, which may include fluid management, pharmacologic agents and dosing, nutritional recommendations, and patient compliance.

• Identify and treat factors that may complicate the management of ARF, including extremes of blood pressure and underlying infections.

• Adjust medications according to estimated renal function and route of excretion.

• Avoid use of nephrotoxic agents in ARF. if nephrotoxic agents are required, closely monitor drug levels and renal function.

• Assess patients with suspected ARF in a timely manner, and manage or co‐manage the patient with the primary requesting service.

ATTITUDES

Hospitalists should be able to:

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

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

• Communicate with patients and families to explain tests and procedures, and the use and potential side effects of pharmacologic agents.

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

• Recognize indications for specialty consultation, which may include nephrology or urology.

• Initiate prevention measures including dietary modification and renal dosing of medications.

• Employ a multidisciplinary approach, which may include nursing, nutrition and pharmacy services in the care of patients with ARF that begins at admission and continues through all care transitions.

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

• Facilitate discharge planning early during hospitalization, including providing the patient with contact information for follow‐up care.

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

SYSTEM ORGANIZATION AND IMPROVEMENT

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

• Advocate establishing and supporting initiatives that have been shown to reduce incidence of iatrogenic ARF.

• Lead, coordinate or participate in multidisciplinary teams, which may include nephrology, nursing, pharmacy and nutrition services, to improve processes that facilitate early identification of ARF, early discharge planning, and improved patient outcomes.

• Lead, coordinate or participate in multidisciplinary initiatives to promote patient safety and optimize management strategies for ARF.

Acute renal failure (ARF) is defined as a decline in renal function over a period of hours or days, which results in an inability to maintain electrolyte homeostasis and an accumulation of nitrogenous waste products. ARF can be a presenting manifestation of a serious illness requiring hospitalization, or occur as a complication of illness or treatment in a hospitalized patient. the healthcare cost and utilization project (HCUP) estimates 141,000 discharges for ARF in 2002, with mean charges of almost $22,000 per patient. the mean length of stay was 6.7 days for these patients, with an in‐hospital mortality of 10.3%. hospitalists can advocate and initiate prevention strategies to reduce the incidence of ARF. hospitalists may also facilitate expeditious evaluation and management of ARF to improve patient outcomes, optimize resource utilization and reduce length of stay.

KNOWLEDGE

Hospitalists should be able to:

• Define the clinical significance of pre‐renal failure, intrinsic renal disease, and post‐renal failure.

• Describe the symptoms and signs of pre‐renal failure, intrinsic renal failure, and post‐renal failure.

• Distinguish the causes of pre‐renal failure, intrinsic renal failure, and post‐renal failure.

• Identify common electrolyte abnormalities that occur with acute renal failure, and institute corrective therapy.

• Describe the indicated tests required to evaluate ARF.

• Calculate estimated creatinine clearance for adjustment of medication dosage when indicated.

• Identify patients at risk for ARF and institute preventive measures, which may include intravenous fluid and acetylcysteine in patients receiving radiocontrast media.

• Identify hospitalized patients at risk for ARF and institute preventive measures.

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

• Describe indications for acute hemodialysis.

• Identify clinical, laboratory and imaging studies that indicate severity of disease.

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

SKILLS

Hospitalists should be able to:

• Elicit a thorough and relevant history and review the medical record for factors predisposing or contributing to the development of ARF.

• Review all drug use including prescription and over‐the‐counter medications, herbal remedies, nutritional supplements, and illicit drugs.

• Perform a physical examination to assess volume status and to identify underlying co‐morbid states that may result in ARF.

• Order and interpret indicated diagnostic studies that may include urinalysis and microscopic sediment analysis, urinary diagnostic indices, urinary protein excretion, serologic evaluation, and renal imaging.

• Avoid use of radiographic contrast agents and order non‐ionic agents when available.

• Identify patients who may benefit from early hemodialysis.

• Determine or coordinate appropriate nutritional and metabolic interventions.

• Formulate a treatment plan tailored to the individual patient, which may include fluid management, pharmacologic agents and dosing, nutritional recommendations, and patient compliance.

• Identify and treat factors that may complicate the management of ARF, including extremes of blood pressure and underlying infections.

• Adjust medications according to estimated renal function and route of excretion.

• Avoid use of nephrotoxic agents in ARF. if nephrotoxic agents are required, closely monitor drug levels and renal function.

• Assess patients with suspected ARF in a timely manner, and manage or co‐manage the patient with the primary requesting service.

ATTITUDES

Hospitalists should be able to:

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

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

• Communicate with patients and families to explain tests and procedures, and the use and potential side effects of pharmacologic agents.

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

• Recognize indications for specialty consultation, which may include nephrology or urology.

• Initiate prevention measures including dietary modification and renal dosing of medications.

• Employ a multidisciplinary approach, which may include nursing, nutrition and pharmacy services in the care of patients with ARF that begins at admission and continues through all care transitions.

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

• Facilitate discharge planning early during hospitalization, including providing the patient with contact information for follow‐up care.

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

SYSTEM ORGANIZATION AND IMPROVEMENT

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

• Advocate establishing and supporting initiatives that have been shown to reduce incidence of iatrogenic ARF.

• Lead, coordinate or participate in multidisciplinary teams, which may include nephrology, nursing, pharmacy and nutrition services, to improve processes that facilitate early identification of ARF, early discharge planning, and improved patient outcomes.

• Lead, coordinate or participate in multidisciplinary initiatives to promote patient safety and optimize management strategies for ARF.

Acute renal failure (ARF) is defined as a decline in renal function over a period of hours or days, which results in an inability to maintain electrolyte homeostasis and an accumulation of nitrogenous waste products. ARF can be a presenting manifestation of a serious illness requiring hospitalization, or occur as a complication of illness or treatment in a hospitalized patient. the healthcare cost and utilization project (HCUP) estimates 141,000 discharges for ARF in 2002, with mean charges of almost $22,000 per patient. the mean length of stay was 6.7 days for these patients, with an in‐hospital mortality of 10.3%. hospitalists can advocate and initiate prevention strategies to reduce the incidence of ARF. hospitalists may also facilitate expeditious evaluation and management of ARF to improve patient outcomes, optimize resource utilization and reduce length of stay.

KNOWLEDGE

Hospitalists should be able to:

• Define the clinical significance of pre‐renal failure, intrinsic renal disease, and post‐renal failure.

• Describe the symptoms and signs of pre‐renal failure, intrinsic renal failure, and post‐renal failure.

• Distinguish the causes of pre‐renal failure, intrinsic renal failure, and post‐renal failure.

• Identify common electrolyte abnormalities that occur with acute renal failure, and institute corrective therapy.

• Describe the indicated tests required to evaluate ARF.

• Calculate estimated creatinine clearance for adjustment of medication dosage when indicated.

• Identify patients at risk for ARF and institute preventive measures, which may include intravenous fluid and acetylcysteine in patients receiving radiocontrast media.

• Identify hospitalized patients at risk for ARF and institute preventive measures.

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

• Describe indications for acute hemodialysis.

• Identify clinical, laboratory and imaging studies that indicate severity of disease.

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

SKILLS

Hospitalists should be able to:

• Elicit a thorough and relevant history and review the medical record for factors predisposing or contributing to the development of ARF.

• Review all drug use including prescription and over‐the‐counter medications, herbal remedies, nutritional supplements, and illicit drugs.

• Perform a physical examination to assess volume status and to identify underlying co‐morbid states that may result in ARF.

• Order and interpret indicated diagnostic studies that may include urinalysis and microscopic sediment analysis, urinary diagnostic indices, urinary protein excretion, serologic evaluation, and renal imaging.

• Avoid use of radiographic contrast agents and order non‐ionic agents when available.

• Identify patients who may benefit from early hemodialysis.

• Determine or coordinate appropriate nutritional and metabolic interventions.

• Formulate a treatment plan tailored to the individual patient, which may include fluid management, pharmacologic agents and dosing, nutritional recommendations, and patient compliance.

• Identify and treat factors that may complicate the management of ARF, including extremes of blood pressure and underlying infections.

• Adjust medications according to estimated renal function and route of excretion.

• Avoid use of nephrotoxic agents in ARF. if nephrotoxic agents are required, closely monitor drug levels and renal function.

• Assess patients with suspected ARF in a timely manner, and manage or co‐manage the patient with the primary requesting service.

ATTITUDES

Hospitalists should be able to:

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

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

• Communicate with patients and families to explain tests and procedures, and the use and potential side effects of pharmacologic agents.

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

• Recognize indications for specialty consultation, which may include nephrology or urology.

• Initiate prevention measures including dietary modification and renal dosing of medications.

• Employ a multidisciplinary approach, which may include nursing, nutrition and pharmacy services in the care of patients with ARF that begins at admission and continues through all care transitions.

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

• Facilitate discharge planning early during hospitalization, including providing the patient with contact information for follow‐up care.

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

SYSTEM ORGANIZATION AND IMPROVEMENT

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

• Advocate establishing and supporting initiatives that have been shown to reduce incidence of iatrogenic ARF.

• Lead, coordinate or participate in multidisciplinary teams, which may include nephrology, nursing, pharmacy and nutrition services, to improve processes that facilitate early identification of ARF, early discharge planning, and improved patient outcomes.

• Lead, coordinate or participate in multidisciplinary initiatives to promote patient safety and optimize management strategies for ARF.

Hospitalists may provide expert medical opinion regarding the care of hospitalized patients or may serve as consultants for patients under the care of other medical and surgical services. The hospitalist consultant may provide opinions and recommendations or actively manage the patient's hospital care. Effective and frequent communication between the hospitalist and the requesting physician ensures safe and quality care. Hospitalists should promote communication between services to improve the care of the hospitalized patient, optimize resource utilization, and enhance patient safety.

KNOWLEDGE

Hospitalists should be able to:

• Define the role of the hospitalist consultant.

• Describe the components of an effective consultation.

• Assess the urgency of the consultation and the questions posed by the requesting physician.

• List factors that may affect implementation of consultant's recommendations.

SKILLS

Hospitalists should be able to:

• Obtain a thorough and relevant history and review the medical record.

• Perform a relevant physical examination.

• Interpret indicated diagnostic studies.

• Synthesize a treatment plan based on the data obtained from the history, physical examination and diagnostic studies.

• Summarize the findings in the patient record.

• List concise but specific recommendations for management.

• Communicate recommendations to the consulting physician in an expedient and efficient manner.

• Assess the level of care required, and communicate with the requesting physician if a transition of care is advised.

ATTITUDES

Hospitalists should be able to:

• Determine the hospitalist consultant's role in collaboration with the requesting physician.

• Respond promptly to the requesting physician's need for consultation.

• Lead by example by performing consultations in a collegial, professional and non‐confrontational manner.

• Inform and educate the requesting physician of potential complications and opportunities for prevention of complications.

• Provide frequent follow‐up, including review of pertinent findings and laboratory data, and ensure that critical recommendations have been followed.

• Provide timely and effective communication with the requesting physician/team.

• Transmit written communication legibly and with clear contact information.

• Recognize when the hospitalist's role in the patient's care is complete, document final recommendations in the medical record, and maintain availability.

• Communicate with patient and family to convey recommendations and treatment plans.

• Recognize the importance of arranging appropriate follow‐up.

• Lead, coordinate or participate in multidisciplinary initiatives to promote patient safety and optimize resource utilization.

Hospitalists may provide expert medical opinion regarding the care of hospitalized patients or may serve as consultants for patients under the care of other medical and surgical services. The hospitalist consultant may provide opinions and recommendations or actively manage the patient's hospital care. Effective and frequent communication between the hospitalist and the requesting physician ensures safe and quality care. Hospitalists should promote communication between services to improve the care of the hospitalized patient, optimize resource utilization, and enhance patient safety.

KNOWLEDGE

Hospitalists should be able to:

• Define the role of the hospitalist consultant.

• Describe the components of an effective consultation.

• Assess the urgency of the consultation and the questions posed by the requesting physician.

• List factors that may affect implementation of consultant's recommendations.

SKILLS

Hospitalists should be able to:

• Obtain a thorough and relevant history and review the medical record.

• Perform a relevant physical examination.

• Interpret indicated diagnostic studies.

• Synthesize a treatment plan based on the data obtained from the history, physical examination and diagnostic studies.

• Summarize the findings in the patient record.

• List concise but specific recommendations for management.

• Communicate recommendations to the consulting physician in an expedient and efficient manner.

• Assess the level of care required, and communicate with the requesting physician if a transition of care is advised.

ATTITUDES

Hospitalists should be able to:

• Determine the hospitalist consultant's role in collaboration with the requesting physician.

• Respond promptly to the requesting physician's need for consultation.

• Lead by example by performing consultations in a collegial, professional and non‐confrontational manner.

• Inform and educate the requesting physician of potential complications and opportunities for prevention of complications.

• Provide frequent follow‐up, including review of pertinent findings and laboratory data, and ensure that critical recommendations have been followed.

• Provide timely and effective communication with the requesting physician/team.

• Transmit written communication legibly and with clear contact information.

• Recognize when the hospitalist's role in the patient's care is complete, document final recommendations in the medical record, and maintain availability.

• Communicate with patient and family to convey recommendations and treatment plans.

• Recognize the importance of arranging appropriate follow‐up.

• Lead, coordinate or participate in multidisciplinary initiatives to promote patient safety and optimize resource utilization.

Hospitalists may provide expert medical opinion regarding the care of hospitalized patients or may serve as consultants for patients under the care of other medical and surgical services. The hospitalist consultant may provide opinions and recommendations or actively manage the patient's hospital care. Effective and frequent communication between the hospitalist and the requesting physician ensures safe and quality care. Hospitalists should promote communication between services to improve the care of the hospitalized patient, optimize resource utilization, and enhance patient safety.

KNOWLEDGE

Hospitalists should be able to:

• Define the role of the hospitalist consultant.

• Describe the components of an effective consultation.

• Assess the urgency of the consultation and the questions posed by the requesting physician.

• List factors that may affect implementation of consultant's recommendations.

SKILLS

Hospitalists should be able to:

• Obtain a thorough and relevant history and review the medical record.

• Perform a relevant physical examination.

• Interpret indicated diagnostic studies.

• Synthesize a treatment plan based on the data obtained from the history, physical examination and diagnostic studies.

• Summarize the findings in the patient record.

• List concise but specific recommendations for management.

• Communicate recommendations to the consulting physician in an expedient and efficient manner.

• Assess the level of care required, and communicate with the requesting physician if a transition of care is advised.

ATTITUDES

Hospitalists should be able to:

• Determine the hospitalist consultant's role in collaboration with the requesting physician.

• Respond promptly to the requesting physician's need for consultation.

• Lead by example by performing consultations in a collegial, professional and non‐confrontational manner.

• Inform and educate the requesting physician of potential complications and opportunities for prevention of complications.

• Provide frequent follow‐up, including review of pertinent findings and laboratory data, and ensure that critical recommendations have been followed.

• Provide timely and effective communication with the requesting physician/team.

• Transmit written communication legibly and with clear contact information.

• Recognize when the hospitalist's role in the patient's care is complete, document final recommendations in the medical record, and maintain availability.

• Communicate with patient and family to convey recommendations and treatment plans.

• Recognize the importance of arranging appropriate follow‐up.

• Lead, coordinate or participate in multidisciplinary initiatives to promote patient safety and optimize resource utilization.

Michael J. Pistoria, DO, FACP

Associate Program Director, Internal Medicine Program; Medical Director, Hospitalist Services

Lehigh Valley Hospital, Allentown, PA

Assistant Professor of Medicine, The Pennsylvania State University College of Medicine

Hershey, PA

Alpesh N. Amin, MD, MBA, FACP

Executive Director, Hospitalist Program

Vice Chair for Clinical Affairs and Quality, Department of Medicine

Associate Program Director, Internal Medicine Residency

Medicine Clerkship Director

University of California, Irvine

Orange, CA

Daniel D. Dressler, MD, MSc

Director, Hospital Medicine Services, Emory University Hospital

Assistant Professor of Medicine, Emory University School of Medicine

Atlanta, GA

Sylvia C.W. McKean, MD

Medical Director, Brigham and Women's Faulkner Hospitalist Service

Assistant Professor of Medicine, Harvard Medical School

Boston, MA

Tina L. Budnitz, MPH

Senior Advisor for New Initiatives

Society of Hospital Medicine

Philadelphia, PA

CONTRIBUTORS

Michael J. Pistoria, DO, FACP

Associate Program Director, Internal Medicine Program; Medical Director, Hospitalist Services

Lehigh Valley Hospital, Allentown, PA

Assistant Professor of Medicine, The Pennsylvania State University College of Medicine

Hershey, PA

Alpesh N. Amin, MD, MBA, FACP

Executive Director, Hospitalist Program

Vice Chair for Clinical Affairs and Quality, Department of Medicine

Associate Program Director, Internal Medicine Residency

Medicine Clerkship Director

University of California, Irvine

Orange, CA

Daniel D. Dressler, MD, MSc

Director, Hospital Medicine Services, Emory University Hospital

Assistant Professor of Medicine, Emory University School of Medicine

Atlanta, GA

Sylvia C.W. McKean, MD

Medical Director, Brigham and Women's Faulkner Hospitalist Service

Assistant Professor of Medicine, Harvard Medical School

Boston, MA

Tina L. Budnitz, MPH

Senior Advisor for New Initiatives

Society of Hospital Medicine

Philadelphia, PA

CONTRIBUTORS

Michael J. Pistoria, DO, FACP

Associate Program Director, Internal Medicine Program; Medical Director, Hospitalist Services

Lehigh Valley Hospital, Allentown, PA

Assistant Professor of Medicine, The Pennsylvania State University College of Medicine

Hershey, PA

Alpesh N. Amin, MD, MBA, FACP

Executive Director, Hospitalist Program

Vice Chair for Clinical Affairs and Quality, Department of Medicine

Associate Program Director, Internal Medicine Residency

Medicine Clerkship Director

University of California, Irvine

Orange, CA

Daniel D. Dressler, MD, MSc

Director, Hospital Medicine Services, Emory University Hospital

Assistant Professor of Medicine, Emory University School of Medicine

Atlanta, GA

Sylvia C.W. McKean, MD

Medical Director, Brigham and Women's Faulkner Hospitalist Service

Assistant Professor of Medicine, Harvard Medical School

Boston, MA

Tina L. Budnitz, MPH

Senior Advisor for New Initiatives

Society of Hospital Medicine

Philadelphia, PA

CONTRIBUTORS

Chest radiographs (CXRs) utilize low‐level radiation to form images of the chest anatomy. They are non‐invasive and readily available. CXRs are an integral part of the initial evaluation of cardiopulmonary pathology. Hospitalists interpret the results of CXRs, often before radiologists, to diagnose disease and develop treatment plans in hospitalized patients.

KNOWLEDGE

Hospitalists should be able to:

• Explain the normal anatomy of the thorax with particular attention to spatial relationships.

• Explain the images seen on a CXR, including bone and soft tissue structures, airway, lungs, cardiac structure and silhouette, aorta, and diaphragm.

• List the indications for ordering a CXR.

• Describe evidence based national guidelines for ordering CXRs.

• Compare the diagnostic utility and limitations of portable radiographs to posteroanterior and lateral radiographs.

• Explain the indications for a lateral decubitus CXR.

• Describe the effects of film exposure, inspiratory effort, and patient position on the radiographic image.

• Explain the effect of cardiovascular, systemic, and traumatic processes on the CXR.

• Explain the limitations of various CXR findings.

SKILLS

Hospitalists should be able to:

• Review a CXR utilizing a systemic approach.

• Identify normal variants.

• Identify abnormalities shown on a CSR and, when possible, correlate with clinical presentation and/or prior procedures.

• Correlate physical examination findings with CXR abnormalities.

• Synthesize CXR findings with other clinical and diagnostic information to diagnose disease and develop a clinical plan.

ATTITUDES

Hospitalists should be able to:

• Communicate with patients and families to explain results of CXRs and how the findings influence the care plan.

• Personally and promptly interpret CXRs and compare them to previously obtained CXRs, when available.

• Review each CXR with a standard and consistent approach.

• Consult and collaborate with radiologists in interpreting complex CXRs and in ordering further diagnostic studies or procedures based on CXR interpretation.

• Utilize evidence based national guidelines to ensure cost efficiency and to minimize unnecessary patient imaging.

SYSTEM ORGANIZATION AND IMPROVEMENT

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

• Lead, coordinate or participate in efforts to develop protocols to minimize unnecessary CXRs.

• Identify and convey the need for system improvements related to acquisition and interpretation of CXRs for hospitalized patients.

Chest radiographs (CXRs) utilize low‐level radiation to form images of the chest anatomy. They are non‐invasive and readily available. CXRs are an integral part of the initial evaluation of cardiopulmonary pathology. Hospitalists interpret the results of CXRs, often before radiologists, to diagnose disease and develop treatment plans in hospitalized patients.

KNOWLEDGE

Hospitalists should be able to:

• Explain the normal anatomy of the thorax with particular attention to spatial relationships.

• Explain the images seen on a CXR, including bone and soft tissue structures, airway, lungs, cardiac structure and silhouette, aorta, and diaphragm.

• List the indications for ordering a CXR.

• Describe evidence based national guidelines for ordering CXRs.

• Compare the diagnostic utility and limitations of portable radiographs to posteroanterior and lateral radiographs.

• Explain the indications for a lateral decubitus CXR.

• Describe the effects of film exposure, inspiratory effort, and patient position on the radiographic image.

• Explain the effect of cardiovascular, systemic, and traumatic processes on the CXR.

• Explain the limitations of various CXR findings.

SKILLS

Hospitalists should be able to:

• Review a CXR utilizing a systemic approach.

• Identify normal variants.

• Identify abnormalities shown on a CSR and, when possible, correlate with clinical presentation and/or prior procedures.

• Correlate physical examination findings with CXR abnormalities.

• Synthesize CXR findings with other clinical and diagnostic information to diagnose disease and develop a clinical plan.

ATTITUDES

Hospitalists should be able to:

• Communicate with patients and families to explain results of CXRs and how the findings influence the care plan.

• Personally and promptly interpret CXRs and compare them to previously obtained CXRs, when available.

• Review each CXR with a standard and consistent approach.

• Consult and collaborate with radiologists in interpreting complex CXRs and in ordering further diagnostic studies or procedures based on CXR interpretation.

• Utilize evidence based national guidelines to ensure cost efficiency and to minimize unnecessary patient imaging.

SYSTEM ORGANIZATION AND IMPROVEMENT

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

• Lead, coordinate or participate in efforts to develop protocols to minimize unnecessary CXRs.

• Identify and convey the need for system improvements related to acquisition and interpretation of CXRs for hospitalized patients.

Chest radiographs (CXRs) utilize low‐level radiation to form images of the chest anatomy. They are non‐invasive and readily available. CXRs are an integral part of the initial evaluation of cardiopulmonary pathology. Hospitalists interpret the results of CXRs, often before radiologists, to diagnose disease and develop treatment plans in hospitalized patients.

KNOWLEDGE

Hospitalists should be able to:

• Explain the normal anatomy of the thorax with particular attention to spatial relationships.

• Explain the images seen on a CXR, including bone and soft tissue structures, airway, lungs, cardiac structure and silhouette, aorta, and diaphragm.

• List the indications for ordering a CXR.

• Describe evidence based national guidelines for ordering CXRs.

• Compare the diagnostic utility and limitations of portable radiographs to posteroanterior and lateral radiographs.

• Explain the indications for a lateral decubitus CXR.

• Describe the effects of film exposure, inspiratory effort, and patient position on the radiographic image.

• Explain the effect of cardiovascular, systemic, and traumatic processes on the CXR.

• Explain the limitations of various CXR findings.

SKILLS

Hospitalists should be able to:

• Review a CXR utilizing a systemic approach.

• Identify normal variants.

• Identify abnormalities shown on a CSR and, when possible, correlate with clinical presentation and/or prior procedures.

• Correlate physical examination findings with CXR abnormalities.

• Synthesize CXR findings with other clinical and diagnostic information to diagnose disease and develop a clinical plan.

ATTITUDES

Hospitalists should be able to:

• Communicate with patients and families to explain results of CXRs and how the findings influence the care plan.

• Personally and promptly interpret CXRs and compare them to previously obtained CXRs, when available.

• Review each CXR with a standard and consistent approach.

• Consult and collaborate with radiologists in interpreting complex CXRs and in ordering further diagnostic studies or procedures based on CXR interpretation.

• Utilize evidence based national guidelines to ensure cost efficiency and to minimize unnecessary patient imaging.

SYSTEM ORGANIZATION AND IMPROVEMENT

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

• Lead, coordinate or participate in efforts to develop protocols to minimize unnecessary CXRs.

• Identify and convey the need for system improvements related to acquisition and interpretation of CXRs for hospitalized patients.

Sepsis syndrome is defined as infection associated with the Systemic Inflammatory Response Syndrome (SIRS). Sepsis has various etiologies and clinical presentations. It accounts for substantial morbidity and mortality. The Healthcare Cost and Utilization Project (HCUP) estimated 300,000 discharges for sepsis syndrome in 2002, with an in‐hospital mortality of 18.6%. The mean length‐of‐stay was 7.3 days with approximately $26,000 in charges per patient. Sepsis requires expeditious diagnosis and standardized treatment plans to favorably impact patient morbidity and mortality. Hospitalists play a key role in the early identification of patients with sepsis, and practice aggressive evidence based evaluation and interventions. Hospitalists lead their institutions to implement early diagnostic strategies, initiate evidence based medical therapies, and incorporate multidisciplinary approaches to the care of patients with sepsis.

KNOWLEDGE

Hospitalists should be able to:

• Define and differentiate bacteremia and the clinical spectrum of SIRS, sepsis, severe sepsis, and septic shock.

• Describe the symptoms and signs of SIRS, sepsis, severe sepsis, and septic shock.

• Describe the inflammatory cascade that leads to SIRS and sepsis.

• Distinguish infectious causes of SIRS from other etiologies.

• Distinguish septic shock from other causes of shock.

• Describe the indicated tests required to evaluate sepsis.

• Identify patient groups with increased risk for the development of sepsis, increased morbidity or mortality, or uncommon etiologic organisms.

• Discuss the evidence based diagnostic choices available in the evaluation of sepsis.

• Describe the indications, contraindications and side effects of therapeutic agents including fluids, vasopressors, antibiotics, steroids, activated protein C, and blood products in the treatment of sepsis.

• Explain indications, contraindications and mechanisms of action of pharmacologic agents used to treat sepsis syndrome.

• Describe the indications for and limitations of central venous access and its value for hemodynamic monitoring and administration of vasoactive agents.

• Describe the role of established scoring systems to estimate the severity of sepsis.

• 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:

• Utilize all available information, including medical records and history provided by patient and care givers, to identify factors that contribute to the development of sepsis.

• Perform a rapid and targeted physical examination to identify potential sources of sepsis.

• Recognize the value and limitations of the history and physical examination in determining the cause of sepsis.

• Order indicated diagnostic testing to identify the source of sepsis and determine severity of organ dysfunction.

• Rapidly identify patients with septic shock and aggressively treat in parallel with transfer to a critical care setting.

• Assess cardiopulmonary stability and implement aggressive fluid resuscitation, airway maintenance and circulatory support.

• Initiate empiric antimicrobial therapy based on the suspected etiologic source of infection.

• Assess the need for central venous access and monitoring; when needed, coordinate or establish central venous access.

• Determine or coordinate appropriate nutritional and metabolic interventions.

• Support organ function and correct metabolic derangements when indicated.

• Implement measures to ensure strict glycemic control.

• Adopt measures to prevent complications, which may include aspiration precautions, stress ulcer and VTE prophylaxis, and decubitus ulcer prevention.

• Measure and interpret indicated hemodynamic monitoring parameters.

ATTITUDES

Hospitalists should be able to:

• Communicate with patients and families to explain the history and prognosis of sepsis and indicators of functional improvement or decline.

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

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

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

• Employ an early and multidisciplinary approach, which may include respiratory therapy, nursing, pharmacy, nutrition, rehabilitation and social services, that begins at admission and continues through all care transitions.

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

• Address resuscitation status early during hospital stay, and discuss and implement end of life decisions by patient or family when indicated or desired.

• Ensure good communication with patients and receiving physicians during care transitions.

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

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 sepsis.

• 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 to promote patient safety and optimize resource utilization.

• Lead, coordinate or participate in intra‐ and inter‐institutional efforts to develop protocols for the rapid identification and transfer of patients with sepsis to appropriate facilities.

• Lead, coordinate or participate in multidisciplinary teams, which may include nutrition, pharmacy, rehabilitation, social services and respiratory therapy, early in the hospital course to improve patient function and outcomes.

• Integrate outcomes research, institution‐specific laboratory policies, and hospital formulary to create indicated and cost‐effective diagnostic and management strategies for patients with sepsis.

Sepsis syndrome is defined as infection associated with the Systemic Inflammatory Response Syndrome (SIRS). Sepsis has various etiologies and clinical presentations. It accounts for substantial morbidity and mortality. The Healthcare Cost and Utilization Project (HCUP) estimated 300,000 discharges for sepsis syndrome in 2002, with an in‐hospital mortality of 18.6%. The mean length‐of‐stay was 7.3 days with approximately $26,000 in charges per patient. Sepsis requires expeditious diagnosis and standardized treatment plans to favorably impact patient morbidity and mortality. Hospitalists play a key role in the early identification of patients with sepsis, and practice aggressive evidence based evaluation and interventions. Hospitalists lead their institutions to implement early diagnostic strategies, initiate evidence based medical therapies, and incorporate multidisciplinary approaches to the care of patients with sepsis.

KNOWLEDGE

Hospitalists should be able to:

• Define and differentiate bacteremia and the clinical spectrum of SIRS, sepsis, severe sepsis, and septic shock.

• Describe the symptoms and signs of SIRS, sepsis, severe sepsis, and septic shock.

• Describe the inflammatory cascade that leads to SIRS and sepsis.

• Distinguish infectious causes of SIRS from other etiologies.

• Distinguish septic shock from other causes of shock.

• Describe the indicated tests required to evaluate sepsis.

• Identify patient groups with increased risk for the development of sepsis, increased morbidity or mortality, or uncommon etiologic organisms.

• Discuss the evidence based diagnostic choices available in the evaluation of sepsis.

• Describe the indications, contraindications and side effects of therapeutic agents including fluids, vasopressors, antibiotics, steroids, activated protein C, and blood products in the treatment of sepsis.

• Explain indications, contraindications and mechanisms of action of pharmacologic agents used to treat sepsis syndrome.

• Describe the indications for and limitations of central venous access and its value for hemodynamic monitoring and administration of vasoactive agents.

• Describe the role of established scoring systems to estimate the severity of sepsis.

• 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:

• Utilize all available information, including medical records and history provided by patient and care givers, to identify factors that contribute to the development of sepsis.

• Perform a rapid and targeted physical examination to identify potential sources of sepsis.

• Recognize the value and limitations of the history and physical examination in determining the cause of sepsis.

• Order indicated diagnostic testing to identify the source of sepsis and determine severity of organ dysfunction.

• Rapidly identify patients with septic shock and aggressively treat in parallel with transfer to a critical care setting.

• Assess cardiopulmonary stability and implement aggressive fluid resuscitation, airway maintenance and circulatory support.

• Initiate empiric antimicrobial therapy based on the suspected etiologic source of infection.

• Assess the need for central venous access and monitoring; when needed, coordinate or establish central venous access.

• Determine or coordinate appropriate nutritional and metabolic interventions.

• Support organ function and correct metabolic derangements when indicated.

• Implement measures to ensure strict glycemic control.

• Adopt measures to prevent complications, which may include aspiration precautions, stress ulcer and VTE prophylaxis, and decubitus ulcer prevention.

• Measure and interpret indicated hemodynamic monitoring parameters.

ATTITUDES

Hospitalists should be able to:

• Communicate with patients and families to explain the history and prognosis of sepsis and indicators of functional improvement or decline.

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

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

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

• Employ an early and multidisciplinary approach, which may include respiratory therapy, nursing, pharmacy, nutrition, rehabilitation and social services, that begins at admission and continues through all care transitions.

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

• Address resuscitation status early during hospital stay, and discuss and implement end of life decisions by patient or family when indicated or desired.

• Ensure good communication with patients and receiving physicians during care transitions.

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

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 sepsis.

• 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 to promote patient safety and optimize resource utilization.

• Lead, coordinate or participate in intra‐ and inter‐institutional efforts to develop protocols for the rapid identification and transfer of patients with sepsis to appropriate facilities.

• Lead, coordinate or participate in multidisciplinary teams, which may include nutrition, pharmacy, rehabilitation, social services and respiratory therapy, early in the hospital course to improve patient function and outcomes.

• Integrate outcomes research, institution‐specific laboratory policies, and hospital formulary to create indicated and cost‐effective diagnostic and management strategies for patients with sepsis.

Sepsis syndrome is defined as infection associated with the Systemic Inflammatory Response Syndrome (SIRS). Sepsis has various etiologies and clinical presentations. It accounts for substantial morbidity and mortality. The Healthcare Cost and Utilization Project (HCUP) estimated 300,000 discharges for sepsis syndrome in 2002, with an in‐hospital mortality of 18.6%. The mean length‐of‐stay was 7.3 days with approximately $26,000 in charges per patient. Sepsis requires expeditious diagnosis and standardized treatment plans to favorably impact patient morbidity and mortality. Hospitalists play a key role in the early identification of patients with sepsis, and practice aggressive evidence based evaluation and interventions. Hospitalists lead their institutions to implement early diagnostic strategies, initiate evidence based medical therapies, and incorporate multidisciplinary approaches to the care of patients with sepsis.

KNOWLEDGE

Hospitalists should be able to:

• Define and differentiate bacteremia and the clinical spectrum of SIRS, sepsis, severe sepsis, and septic shock.

• Describe the symptoms and signs of SIRS, sepsis, severe sepsis, and septic shock.

• Describe the inflammatory cascade that leads to SIRS and sepsis.

• Distinguish infectious causes of SIRS from other etiologies.

• Distinguish septic shock from other causes of shock.

• Describe the indicated tests required to evaluate sepsis.

• Identify patient groups with increased risk for the development of sepsis, increased morbidity or mortality, or uncommon etiologic organisms.

• Discuss the evidence based diagnostic choices available in the evaluation of sepsis.

• Describe the indications, contraindications and side effects of therapeutic agents including fluids, vasopressors, antibiotics, steroids, activated protein C, and blood products in the treatment of sepsis.

• Explain indications, contraindications and mechanisms of action of pharmacologic agents used to treat sepsis syndrome.

• Describe the indications for and limitations of central venous access and its value for hemodynamic monitoring and administration of vasoactive agents.

• Describe the role of established scoring systems to estimate the severity of sepsis.

• 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:

• Utilize all available information, including medical records and history provided by patient and care givers, to identify factors that contribute to the development of sepsis.

• Perform a rapid and targeted physical examination to identify potential sources of sepsis.

• Recognize the value and limitations of the history and physical examination in determining the cause of sepsis.

• Order indicated diagnostic testing to identify the source of sepsis and determine severity of organ dysfunction.

• Rapidly identify patients with septic shock and aggressively treat in parallel with transfer to a critical care setting.

• Assess cardiopulmonary stability and implement aggressive fluid resuscitation, airway maintenance and circulatory support.

• Initiate empiric antimicrobial therapy based on the suspected etiologic source of infection.

• Assess the need for central venous access and monitoring; when needed, coordinate or establish central venous access.

• Determine or coordinate appropriate nutritional and metabolic interventions.

• Support organ function and correct metabolic derangements when indicated.

• Implement measures to ensure strict glycemic control.

• Adopt measures to prevent complications, which may include aspiration precautions, stress ulcer and VTE prophylaxis, and decubitus ulcer prevention.

• Measure and interpret indicated hemodynamic monitoring parameters.

ATTITUDES

Hospitalists should be able to:

• Communicate with patients and families to explain the history and prognosis of sepsis and indicators of functional improvement or decline.

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

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

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

• Employ an early and multidisciplinary approach, which may include respiratory therapy, nursing, pharmacy, nutrition, rehabilitation and social services, that begins at admission and continues through all care transitions.

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

• Address resuscitation status early during hospital stay, and discuss and implement end of life decisions by patient or family when indicated or desired.

• Ensure good communication with patients and receiving physicians during care transitions.

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

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 sepsis.

• 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 to promote patient safety and optimize resource utilization.

• Lead, coordinate or participate in intra‐ and inter‐institutional efforts to develop protocols for the rapid identification and transfer of patients with sepsis to appropriate facilities.

• Lead, coordinate or participate in multidisciplinary teams, which may include nutrition, pharmacy, rehabilitation, social services and respiratory therapy, early in the hospital course to improve patient function and outcomes.

• Integrate outcomes research, institution‐specific laboratory policies, and hospital formulary to create indicated and cost‐effective diagnostic and management strategies for patients with sepsis.

Palliative care refers to a collaborative, comprehensive, interdisciplinary approach to improve the quality of life of patients living with debilitating, chronic or terminal illness. Palliative care is appropriate at any stage of illness and should be provided simultaneously with all other medical treatments. This approach includes the prevention and relief of suffering by means of early identification, assessment, and treatment of pain and other distressing symptoms such as dyspnea, nausea, fatigue, anxiety and depression; and attention to the physical, psychosocial and spiritual needs of patients and their families.

Hospitalists provide palliative care in multiple realms including 1) patients dying in the hospital; 2) patients discharged to home or another institution for end‐of‐life care; 3) patients with newly diagnosed life‐threatening illness; 4) patients requiring complex inpatient symptom management interventions; 5) patients for whom it is appropriate to shift the goal of care away from disease cure or stabilization and toward the maximization of comfort; and 6) patients with serious, chronic illness such as heart failure, COPD, liver disease, dementia, and cancer. Hospitalists lead, coordinate, and participate in initiatives to improve the identification and treatment of patients and families in need of palliative care.

KNOWLEDGE

Hospitalists should be able to:

• Determine effective management strategies for patients requiring palliative care.

• Describe potential adverse effects from medications and procedures directed at palliation.

• Formulate strategies for prevention and treatment of complications of palliative care interventions.

• Assess the impact of interventions including feeding tubes, parenteral nutrition, mechanical ventilation, and intravenous fluids on patient comfort and prognosis.

• Describe the concept of double effect with respect to palliative care intervention.

• Name the basic tenets of hospice care and the Medicare hospice benefit.

• Identify indicators of clinical stability that allow for safe transitions of care and continuity after discharge.

• Explain the role of palliative care throughout the course of illness and how it can be provided alongside all other appropriate medical treatments.

• Describe signs and symptoms of the last 24 hours of life and how to discuss these observations with families.

• Describe the responsibilities of the hospitalist after a patient dies, including pronouncing a person dead, completing the death certificate, requesting an autopsy, notifying family and PCP, and contacting the organ donor network.

SKILLS

Hospitalists should be able to:

• Obtain a thorough and relevant history, review the medical record, and perform a comprehensive physical examination to identify symptoms, co‐morbidities, medications or social influences that impact the palliative care plan.

• Direct individual patient's palliative care delivery from admission to discharge.

• Formulate a communication plan for delivering prognostic information.

• Conduct effective and compassionate family meetings.

• Formulate specific patient centered palliative care plans that include pain management; integration of psychiatric, social, spiritual and other support services; and discharge planning.

• Recognize and address the psychosocial effects of complex, acute life threatening illness in hospitalized patients.

• Assess and respond to patient's symptoms, which may include pain, dyspnea, nausea, constipation, fatigue, anorexia, anxiety, depression and delirium.

• Anticipate adverse effects and double effect from interventions and initiate measures to minimize such problems.

• Communicate effectively with patients and families about patient's values and goals of care.

• Communicate effectively with patients and families about hospice and know how to refer a patient to hospice.

• Respond to patient requests for assisted suicide and identify and address other important ethical issues.

ATTITUDES

Hospitalists should be able to:

• Convey diagnosis, prognosis, treatment and support options available for patients and families in a clear, concise, compassionate, culturally sensitive and timely manner.

• Determine patient and family understanding of severity of illness, prognosis and their role in determining the goals of their care.

• Promote the ethical imperative of frequent pain assessment and adequate control.

• Appreciate that all pain is subjective and acknowledge patient's self reports of pain.

• Discuss with patients and families goals for pain management strategies and functional status and set targets for pain control.

• Appreciate that good palliative care for patients with certain conditions often involves the use of therapies typically thought of as curative.

• Conduct meetings with patients and families to establish goals of care that reflect the patient's wishes.

• Determine existence of advance directives and provide patients and families with resources to understand and execute such directives.

• Advocate incorporation of patient wishes into care plans.

• Recognize the need for frequent family meetings.

• Address resuscitation status and patient preferences for care early during hospital stay.

• Maintain rapport with patients and families and a consistent approach to management during transfers of care.

• Recognize impact of cultural and spiritual factors to the provision of palliative care.

• Appreciate the role of other members of the healthcare team including nursing and social services, pharmacy, psychology and pastoral care in providing comprehensive palliative care, and work closely with these team members in caring for patients with serious, chronic and terminal illnesses and their families.

• Provide reassurance to patients and families that clinical providers will be available to provide ongoing care and relief of symptoms.

• Formulate a comprehensive discharge plan that will empower the patient, family and subsequent providers to anticipate and manage changing symptoms, emergency situations, and increasing dependency.

• Lead, coordinate or participate in efforts to establish or improve palliative care in the hospital, which may include establishing a palliative care consultation service.

• Consider palliative care issues at hospital management and committee meetings.

• Engage providers and administrators in the study of local palliative care delivery to include efficacy of pain assessment and intervention, patient and family satisfaction with care delivery, impact on hospital occupancy and costs, and fulfilled expectations of referring and collaborating providers and services.

Palliative care refers to a collaborative, comprehensive, interdisciplinary approach to improve the quality of life of patients living with debilitating, chronic or terminal illness. Palliative care is appropriate at any stage of illness and should be provided simultaneously with all other medical treatments. This approach includes the prevention and relief of suffering by means of early identification, assessment, and treatment of pain and other distressing symptoms such as dyspnea, nausea, fatigue, anxiety and depression; and attention to the physical, psychosocial and spiritual needs of patients and their families.

Hospitalists provide palliative care in multiple realms including 1) patients dying in the hospital; 2) patients discharged to home or another institution for end‐of‐life care; 3) patients with newly diagnosed life‐threatening illness; 4) patients requiring complex inpatient symptom management interventions; 5) patients for whom it is appropriate to shift the goal of care away from disease cure or stabilization and toward the maximization of comfort; and 6) patients with serious, chronic illness such as heart failure, COPD, liver disease, dementia, and cancer. Hospitalists lead, coordinate, and participate in initiatives to improve the identification and treatment of patients and families in need of palliative care.

KNOWLEDGE

Hospitalists should be able to:

• Determine effective management strategies for patients requiring palliative care.

• Describe potential adverse effects from medications and procedures directed at palliation.

• Formulate strategies for prevention and treatment of complications of palliative care interventions.

• Assess the impact of interventions including feeding tubes, parenteral nutrition, mechanical ventilation, and intravenous fluids on patient comfort and prognosis.

• Describe the concept of double effect with respect to palliative care intervention.

• Name the basic tenets of hospice care and the Medicare hospice benefit.

• Identify indicators of clinical stability that allow for safe transitions of care and continuity after discharge.

• Explain the role of palliative care throughout the course of illness and how it can be provided alongside all other appropriate medical treatments.

• Describe signs and symptoms of the last 24 hours of life and how to discuss these observations with families.

• Describe the responsibilities of the hospitalist after a patient dies, including pronouncing a person dead, completing the death certificate, requesting an autopsy, notifying family and PCP, and contacting the organ donor network.

SKILLS

Hospitalists should be able to:

• Obtain a thorough and relevant history, review the medical record, and perform a comprehensive physical examination to identify symptoms, co‐morbidities, medications or social influences that impact the palliative care plan.

• Direct individual patient's palliative care delivery from admission to discharge.

• Formulate a communication plan for delivering prognostic information.

• Conduct effective and compassionate family meetings.

• Formulate specific patient centered palliative care plans that include pain management; integration of psychiatric, social, spiritual and other support services; and discharge planning.

• Recognize and address the psychosocial effects of complex, acute life threatening illness in hospitalized patients.

• Assess and respond to patient's symptoms, which may include pain, dyspnea, nausea, constipation, fatigue, anorexia, anxiety, depression and delirium.

• Anticipate adverse effects and double effect from interventions and initiate measures to minimize such problems.

• Communicate effectively with patients and families about patient's values and goals of care.

• Communicate effectively with patients and families about hospice and know how to refer a patient to hospice.

• Respond to patient requests for assisted suicide and identify and address other important ethical issues.

ATTITUDES

Hospitalists should be able to:

• Convey diagnosis, prognosis, treatment and support options available for patients and families in a clear, concise, compassionate, culturally sensitive and timely manner.

• Determine patient and family understanding of severity of illness, prognosis and their role in determining the goals of their care.

• Promote the ethical imperative of frequent pain assessment and adequate control.

• Appreciate that all pain is subjective and acknowledge patient's self reports of pain.

• Discuss with patients and families goals for pain management strategies and functional status and set targets for pain control.

• Appreciate that good palliative care for patients with certain conditions often involves the use of therapies typically thought of as curative.

• Conduct meetings with patients and families to establish goals of care that reflect the patient's wishes.

• Determine existence of advance directives and provide patients and families with resources to understand and execute such directives.

• Advocate incorporation of patient wishes into care plans.

• Recognize the need for frequent family meetings.

• Address resuscitation status and patient preferences for care early during hospital stay.

• Maintain rapport with patients and families and a consistent approach to management during transfers of care.

• Recognize impact of cultural and spiritual factors to the provision of palliative care.

• Appreciate the role of other members of the healthcare team including nursing and social services, pharmacy, psychology and pastoral care in providing comprehensive palliative care, and work closely with these team members in caring for patients with serious, chronic and terminal illnesses and their families.

• Provide reassurance to patients and families that clinical providers will be available to provide ongoing care and relief of symptoms.

• Formulate a comprehensive discharge plan that will empower the patient, family and subsequent providers to anticipate and manage changing symptoms, emergency situations, and increasing dependency.

• Lead, coordinate or participate in efforts to establish or improve palliative care in the hospital, which may include establishing a palliative care consultation service.

• Consider palliative care issues at hospital management and committee meetings.

• Engage providers and administrators in the study of local palliative care delivery to include efficacy of pain assessment and intervention, patient and family satisfaction with care delivery, impact on hospital occupancy and costs, and fulfilled expectations of referring and collaborating providers and services.

Palliative care refers to a collaborative, comprehensive, interdisciplinary approach to improve the quality of life of patients living with debilitating, chronic or terminal illness. Palliative care is appropriate at any stage of illness and should be provided simultaneously with all other medical treatments. This approach includes the prevention and relief of suffering by means of early identification, assessment, and treatment of pain and other distressing symptoms such as dyspnea, nausea, fatigue, anxiety and depression; and attention to the physical, psychosocial and spiritual needs of patients and their families.

Hospitalists provide palliative care in multiple realms including 1) patients dying in the hospital; 2) patients discharged to home or another institution for end‐of‐life care; 3) patients with newly diagnosed life‐threatening illness; 4) patients requiring complex inpatient symptom management interventions; 5) patients for whom it is appropriate to shift the goal of care away from disease cure or stabilization and toward the maximization of comfort; and 6) patients with serious, chronic illness such as heart failure, COPD, liver disease, dementia, and cancer. Hospitalists lead, coordinate, and participate in initiatives to improve the identification and treatment of patients and families in need of palliative care.

KNOWLEDGE

Hospitalists should be able to:

• Determine effective management strategies for patients requiring palliative care.

• Describe potential adverse effects from medications and procedures directed at palliation.

• Formulate strategies for prevention and treatment of complications of palliative care interventions.

• Assess the impact of interventions including feeding tubes, parenteral nutrition, mechanical ventilation, and intravenous fluids on patient comfort and prognosis.

• Describe the concept of double effect with respect to palliative care intervention.

• Name the basic tenets of hospice care and the Medicare hospice benefit.

• Identify indicators of clinical stability that allow for safe transitions of care and continuity after discharge.

• Explain the role of palliative care throughout the course of illness and how it can be provided alongside all other appropriate medical treatments.

• Describe signs and symptoms of the last 24 hours of life and how to discuss these observations with families.

• Describe the responsibilities of the hospitalist after a patient dies, including pronouncing a person dead, completing the death certificate, requesting an autopsy, notifying family and PCP, and contacting the organ donor network.

SKILLS

Hospitalists should be able to:

• Obtain a thorough and relevant history, review the medical record, and perform a comprehensive physical examination to identify symptoms, co‐morbidities, medications or social influences that impact the palliative care plan.

• Direct individual patient's palliative care delivery from admission to discharge.

• Formulate a communication plan for delivering prognostic information.

• Conduct effective and compassionate family meetings.

• Formulate specific patient centered palliative care plans that include pain management; integration of psychiatric, social, spiritual and other support services; and discharge planning.

• Recognize and address the psychosocial effects of complex, acute life threatening illness in hospitalized patients.

• Assess and respond to patient's symptoms, which may include pain, dyspnea, nausea, constipation, fatigue, anorexia, anxiety, depression and delirium.

• Anticipate adverse effects and double effect from interventions and initiate measures to minimize such problems.

• Communicate effectively with patients and families about patient's values and goals of care.

• Communicate effectively with patients and families about hospice and know how to refer a patient to hospice.

• Respond to patient requests for assisted suicide and identify and address other important ethical issues.

ATTITUDES

Hospitalists should be able to:

• Convey diagnosis, prognosis, treatment and support options available for patients and families in a clear, concise, compassionate, culturally sensitive and timely manner.

• Determine patient and family understanding of severity of illness, prognosis and their role in determining the goals of their care.

• Promote the ethical imperative of frequent pain assessment and adequate control.

• Appreciate that all pain is subjective and acknowledge patient's self reports of pain.

• Discuss with patients and families goals for pain management strategies and functional status and set targets for pain control.

• Appreciate that good palliative care for patients with certain conditions often involves the use of therapies typically thought of as curative.

• Conduct meetings with patients and families to establish goals of care that reflect the patient's wishes.

• Determine existence of advance directives and provide patients and families with resources to understand and execute such directives.

• Advocate incorporation of patient wishes into care plans.

• Recognize the need for frequent family meetings.

• Address resuscitation status and patient preferences for care early during hospital stay.

• Maintain rapport with patients and families and a consistent approach to management during transfers of care.

• Recognize impact of cultural and spiritual factors to the provision of palliative care.

• Appreciate the role of other members of the healthcare team including nursing and social services, pharmacy, psychology and pastoral care in providing comprehensive palliative care, and work closely with these team members in caring for patients with serious, chronic and terminal illnesses and their families.

• Provide reassurance to patients and families that clinical providers will be available to provide ongoing care and relief of symptoms.

• Formulate a comprehensive discharge plan that will empower the patient, family and subsequent providers to anticipate and manage changing symptoms, emergency situations, and increasing dependency.

• Lead, coordinate or participate in efforts to establish or improve palliative care in the hospital, which may include establishing a palliative care consultation service.

• Consider palliative care issues at hospital management and committee meetings.

• Engage providers and administrators in the study of local palliative care delivery to include efficacy of pain assessment and intervention, patient and family satisfaction with care delivery, impact on hospital occupancy and costs, and fulfilled expectations of referring and collaborating providers and services.

Community‐acquired pneumonia (cap) is an infection of the lung parenchyma that begins in the community and is diagnosed within 48 hours of admission to the hospital. in the u.s. each year, cap is the most common infectious cause of death and the sixth leading cause of death overall in the united states. the healthcare cost and utilization project (hcup) attributed 831,000 discharges to the diagnosis related group (drg) for simple pneumonia in 2002. these patients were hospitalized for a mean of 5.4 days and had an in‐hospital mortality of 4.9%. the mean charges for these patients were $13,000 per patient and the mean length‐of‐stay was 4.7 days with in‐house mortality of 1.7%. quality indicators have been created around the key processes of care for patients with cap, and these indicators are used to evaluate performance of states, healthcare organizations, physician groups, and individual physicians. from admission to discharge, hospitalists apply evidence based practice guidelines to the management of cap and lead initiatives to improve quality of care and reduce practice variability.

KNOWLEDGE

Hospitalists should be able to:

• Define cap, list the likely etiologies and signs and symptoms, and distinguish from hospital‐acquired pneumonia.

• Differentiate cap from other processes that may mimic cap or other causes of infiltrates on chest x‐ray.

• Describe the indicated tests required to evaluate and treat cap.

• Explain indications for respiratory isolation.

• Identify patients with co‐morbidities (such as the immunocompromised patient and those with diabetes mellitus) and extremes of age (the elderly and very young) who are at risk for a complicated course of cap.

• Identify specific pathogens that predispose patients to a complicated course of cap.

• Explain patient specific risk factors and presence of specific organisms that predispose patients to a complicated course of cap.

• Describe indicated therapeutic modalities for cap including oxygen therapy, respiratory care modalities and antibiotic selection.

• Predict patient risk for morbidity and mortality from cap using an evidence based tool such as the pneumonia patient outcomes research team (port) / pneumonia severity index (psi) validated risk score.

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

SKILLS

Hospitalists should be able to:

• Elicit a focused history to identify symptoms consistent with cap and demographic factors that may predispose patients to cap.

• Perform a targeted physical examination to elicit signs consistent with cap and differentiate it from other mimicking conditions.

• Select and interpret indicated laboratory, microbiologic and radiological studies to confirm diagnosis of cap, and risk stratify patients.

• Apply evidence based tools such as the pneumonia severity index, to triage decisions and identify factors that support the need for intensive care unit (icu) admission.

• Initiate empiric antibiotic selection based on exposure to long term or group care, severity of illness, and evidence based national guidelines, taking into account local resistance patterns.

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

• Recognize and address complications of cap and/or inadequate response to therapy including respiratory failure and emerging parapneumonic effusions.

ATTITUDES

Hospitalists should be able to:

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

• Communicate with patients and families to explain the goals of care plan, including clinical stability criteria, the importance of prevention measures such as smoking cessation, and required follow‐up care.

• Communicate with patients and families to explain tests and procedures, and the use and potential side effects of pharmacologic agents.

• Recognize indications for specialty consultation.

• Promote prevention strategies, which may include smoking cessation and indicated vaccinations.

• Collaborate with primary care physicians and emergency physicians in making the admission decision.

• Document treatment plan and discharge instructions, and identify the outpatient clinician responsible for follow‐up of pending tests.

• Recognize and address barriers to follow‐up care and anticipated post‐discharge requirements.

• Utilize evidence based recommendations for the treatment of patients with cap

SYSTEM ORGANIZATION AND IMPROVEMENT

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

• Lead, coordinate or participate in efforts to identify, address and monitor quality indicators for cap including assessment of oxygenation, obtaining blood cultures prior to administration of antibiotics, prompt administration of antibiotics, and providing indicated vaccinations and smoking cessation education.

• Implement systems to ensure hospital wide adherence to national standards and document those measures as specified by recognized organizations (jcaho, idsa, ats)

• Integrate port score / psi in conjunction with patient specific factors and clinical judgment into the admission decision.

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

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

Community‐acquired pneumonia (cap) is an infection of the lung parenchyma that begins in the community and is diagnosed within 48 hours of admission to the hospital. in the u.s. each year, cap is the most common infectious cause of death and the sixth leading cause of death overall in the united states. the healthcare cost and utilization project (hcup) attributed 831,000 discharges to the diagnosis related group (drg) for simple pneumonia in 2002. these patients were hospitalized for a mean of 5.4 days and had an in‐hospital mortality of 4.9%. the mean charges for these patients were $13,000 per patient and the mean length‐of‐stay was 4.7 days with in‐house mortality of 1.7%. quality indicators have been created around the key processes of care for patients with cap, and these indicators are used to evaluate performance of states, healthcare organizations, physician groups, and individual physicians. from admission to discharge, hospitalists apply evidence based practice guidelines to the management of cap and lead initiatives to improve quality of care and reduce practice variability.

KNOWLEDGE

Hospitalists should be able to:

• Define cap, list the likely etiologies and signs and symptoms, and distinguish from hospital‐acquired pneumonia.

• Differentiate cap from other processes that may mimic cap or other causes of infiltrates on chest x‐ray.

• Describe the indicated tests required to evaluate and treat cap.

• Explain indications for respiratory isolation.

• Identify patients with co‐morbidities (such as the immunocompromised patient and those with diabetes mellitus) and extremes of age (the elderly and very young) who are at risk for a complicated course of cap.

• Identify specific pathogens that predispose patients to a complicated course of cap.

• Explain patient specific risk factors and presence of specific organisms that predispose patients to a complicated course of cap.

• Describe indicated therapeutic modalities for cap including oxygen therapy, respiratory care modalities and antibiotic selection.

• Predict patient risk for morbidity and mortality from cap using an evidence based tool such as the pneumonia patient outcomes research team (port) / pneumonia severity index (psi) validated risk score.

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

SKILLS

Hospitalists should be able to:

• Elicit a focused history to identify symptoms consistent with cap and demographic factors that may predispose patients to cap.

• Perform a targeted physical examination to elicit signs consistent with cap and differentiate it from other mimicking conditions.

• Select and interpret indicated laboratory, microbiologic and radiological studies to confirm diagnosis of cap, and risk stratify patients.

• Apply evidence based tools such as the pneumonia severity index, to triage decisions and identify factors that support the need for intensive care unit (icu) admission.

• Initiate empiric antibiotic selection based on exposure to long term or group care, severity of illness, and evidence based national guidelines, taking into account local resistance patterns.

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

• Recognize and address complications of cap and/or inadequate response to therapy including respiratory failure and emerging parapneumonic effusions.

ATTITUDES

Hospitalists should be able to:

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

• Communicate with patients and families to explain the goals of care plan, including clinical stability criteria, the importance of prevention measures such as smoking cessation, and required follow‐up care.

• Communicate with patients and families to explain tests and procedures, and the use and potential side effects of pharmacologic agents.

• Recognize indications for specialty consultation.

• Promote prevention strategies, which may include smoking cessation and indicated vaccinations.

• Collaborate with primary care physicians and emergency physicians in making the admission decision.

• Document treatment plan and discharge instructions, and identify the outpatient clinician responsible for follow‐up of pending tests.

• Recognize and address barriers to follow‐up care and anticipated post‐discharge requirements.

• Utilize evidence based recommendations for the treatment of patients with cap

SYSTEM ORGANIZATION AND IMPROVEMENT

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

• Lead, coordinate or participate in efforts to identify, address and monitor quality indicators for cap including assessment of oxygenation, obtaining blood cultures prior to administration of antibiotics, prompt administration of antibiotics, and providing indicated vaccinations and smoking cessation education.

• Implement systems to ensure hospital wide adherence to national standards and document those measures as specified by recognized organizations (jcaho, idsa, ats)

• Integrate port score / psi in conjunction with patient specific factors and clinical judgment into the admission decision.

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

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

Community‐acquired pneumonia (cap) is an infection of the lung parenchyma that begins in the community and is diagnosed within 48 hours of admission to the hospital. in the u.s. each year, cap is the most common infectious cause of death and the sixth leading cause of death overall in the united states. the healthcare cost and utilization project (hcup) attributed 831,000 discharges to the diagnosis related group (drg) for simple pneumonia in 2002. these patients were hospitalized for a mean of 5.4 days and had an in‐hospital mortality of 4.9%. the mean charges for these patients were $13,000 per patient and the mean length‐of‐stay was 4.7 days with in‐house mortality of 1.7%. quality indicators have been created around the key processes of care for patients with cap, and these indicators are used to evaluate performance of states, healthcare organizations, physician groups, and individual physicians. from admission to discharge, hospitalists apply evidence based practice guidelines to the management of cap and lead initiatives to improve quality of care and reduce practice variability.

KNOWLEDGE

Hospitalists should be able to:

• Define cap, list the likely etiologies and signs and symptoms, and distinguish from hospital‐acquired pneumonia.

• Differentiate cap from other processes that may mimic cap or other causes of infiltrates on chest x‐ray.

• Describe the indicated tests required to evaluate and treat cap.

• Explain indications for respiratory isolation.

• Identify patients with co‐morbidities (such as the immunocompromised patient and those with diabetes mellitus) and extremes of age (the elderly and very young) who are at risk for a complicated course of cap.

• Identify specific pathogens that predispose patients to a complicated course of cap.

• Explain patient specific risk factors and presence of specific organisms that predispose patients to a complicated course of cap.

• Describe indicated therapeutic modalities for cap including oxygen therapy, respiratory care modalities and antibiotic selection.

• Predict patient risk for morbidity and mortality from cap using an evidence based tool such as the pneumonia patient outcomes research team (port) / pneumonia severity index (psi) validated risk score.

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

SKILLS

Hospitalists should be able to:

• Elicit a focused history to identify symptoms consistent with cap and demographic factors that may predispose patients to cap.

• Perform a targeted physical examination to elicit signs consistent with cap and differentiate it from other mimicking conditions.

• Select and interpret indicated laboratory, microbiologic and radiological studies to confirm diagnosis of cap, and risk stratify patients.

• Apply evidence based tools such as the pneumonia severity index, to triage decisions and identify factors that support the need for intensive care unit (icu) admission.

• Initiate empiric antibiotic selection based on exposure to long term or group care, severity of illness, and evidence based national guidelines, taking into account local resistance patterns.

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

• Recognize and address complications of cap and/or inadequate response to therapy including respiratory failure and emerging parapneumonic effusions.

ATTITUDES

Hospitalists should be able to:

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

• Communicate with patients and families to explain the goals of care plan, including clinical stability criteria, the importance of prevention measures such as smoking cessation, and required follow‐up care.

• Communicate with patients and families to explain tests and procedures, and the use and potential side effects of pharmacologic agents.

• Recognize indications for specialty consultation.

• Promote prevention strategies, which may include smoking cessation and indicated vaccinations.

• Collaborate with primary care physicians and emergency physicians in making the admission decision.

• Document treatment plan and discharge instructions, and identify the outpatient clinician responsible for follow‐up of pending tests.

• Recognize and address barriers to follow‐up care and anticipated post‐discharge requirements.

• Utilize evidence based recommendations for the treatment of patients with cap

SYSTEM ORGANIZATION AND IMPROVEMENT

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

• Lead, coordinate or participate in efforts to identify, address and monitor quality indicators for cap including assessment of oxygenation, obtaining blood cultures prior to administration of antibiotics, prompt administration of antibiotics, and providing indicated vaccinations and smoking cessation education.

• Implement systems to ensure hospital wide adherence to national standards and document those measures as specified by recognized organizations (jcaho, idsa, ats)

• Integrate port score / psi in conjunction with patient specific factors and clinical judgment into the admission decision.

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

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