Supplements

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

KNOWLEDGE

Hospitalists should be able to:

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

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

• Describe the indicated tests required to evaluate cellulitis.

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

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

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

• Explain indications for inpatient admission.

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

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

SKILLS

Hospitalists should be able to:

• Elicit a focused history to identify precipitating causes of cellulitis and co‐morbid conditions that may impact clinical management.

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

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

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

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

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

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

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

ATTITUDES

Hospitalists should be able to:

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

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

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

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

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

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

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

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

• Employ multidisciplinary teams to facilitate discharge planning.

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

SYSTEM ORGANIZATIONS AND IMPROVEMENT

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

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

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

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

KNOWLEDGE

Hospitalists should be able to:

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

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

• Describe the indicated tests required to evaluate cellulitis.

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

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

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

• Explain indications for inpatient admission.

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

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

SKILLS

Hospitalists should be able to:

• Elicit a focused history to identify precipitating causes of cellulitis and co‐morbid conditions that may impact clinical management.

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

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

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

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

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

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

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

ATTITUDES

Hospitalists should be able to:

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

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

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

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

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

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

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

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

• Employ multidisciplinary teams to facilitate discharge planning.

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

SYSTEM ORGANIZATIONS AND IMPROVEMENT

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

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

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

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

KNOWLEDGE

Hospitalists should be able to:

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

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

• Describe the indicated tests required to evaluate cellulitis.

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

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

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

• Explain indications for inpatient admission.

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

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

SKILLS

Hospitalists should be able to:

• Elicit a focused history to identify precipitating causes of cellulitis and co‐morbid conditions that may impact clinical management.

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

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

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

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

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

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

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

ATTITUDES

Hospitalists should be able to:

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

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

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

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

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

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

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

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

• Employ multidisciplinary teams to facilitate discharge planning.

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

SYSTEM ORGANIZATIONS AND IMPROVEMENT

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

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

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

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

KNOWLEDGE

Hospitalists should be able to:

• Define hospital‐acquired pneumonia (HAP).

• List common organisms associated with HAP.

• Describe local and national resistance patterns for HAP.

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

• Distinguish the infectious causes of HAP.

• Describe the indicated tests required to evaluate HAP.

• Identify patients at risk for developing HAP.

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

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

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

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

• Describe potential complications of HAP.

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

SKILLS

Hospitalists should be able to:

• Elicit a thorough and relevant history, and perform a targeted physical examination for hospital‐acquired pneumonia.

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

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

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

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

• Coordinate care for patients requiring mechanical ventilation.

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

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

ATTITUDES

Hospitalists should be able to:

• Communicate with patients and families to explain the etiology, management plan, and potential outcomes of hospital‐acquired pneumonia.

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

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

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

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

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

• Recognize implications of HAP on discharge planning.

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

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

SYSTEM ORGANIZATION AND IMPROVEMENT

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

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

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

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

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

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

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

KNOWLEDGE

Hospitalists should be able to:

• Define hospital‐acquired pneumonia (HAP).

• List common organisms associated with HAP.

• Describe local and national resistance patterns for HAP.

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

• Distinguish the infectious causes of HAP.

• Describe the indicated tests required to evaluate HAP.

• Identify patients at risk for developing HAP.

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

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

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

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

• Describe potential complications of HAP.

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

SKILLS

Hospitalists should be able to:

• Elicit a thorough and relevant history, and perform a targeted physical examination for hospital‐acquired pneumonia.

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

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

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

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

• Coordinate care for patients requiring mechanical ventilation.

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

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

ATTITUDES

Hospitalists should be able to:

• Communicate with patients and families to explain the etiology, management plan, and potential outcomes of hospital‐acquired pneumonia.

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

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

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

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

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

• Recognize implications of HAP on discharge planning.

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

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

SYSTEM ORGANIZATION AND IMPROVEMENT

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

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

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

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

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

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

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

KNOWLEDGE

Hospitalists should be able to:

• Define hospital‐acquired pneumonia (HAP).

• List common organisms associated with HAP.

• Describe local and national resistance patterns for HAP.

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

• Distinguish the infectious causes of HAP.

• Describe the indicated tests required to evaluate HAP.

• Identify patients at risk for developing HAP.

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

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

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

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

• Describe potential complications of HAP.

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

SKILLS

Hospitalists should be able to:

• Elicit a thorough and relevant history, and perform a targeted physical examination for hospital‐acquired pneumonia.

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

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

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

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

• Coordinate care for patients requiring mechanical ventilation.

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

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

ATTITUDES

Hospitalists should be able to:

• Communicate with patients and families to explain the etiology, management plan, and potential outcomes of hospital‐acquired pneumonia.

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

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

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

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

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

• Recognize implications of HAP on discharge planning.

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

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

SYSTEM ORGANIZATION AND IMPROVEMENT

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

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

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

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

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

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

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

KNOWLEDGE

Hospitalists should be able to:

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

• Recognize the complications from substance use and dependency.

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

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

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

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

• Identify local trends in illicit drug use.

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

• Explain patient characteristics that on admission portend poor prognosis.

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

SKILLS

Hospitalists should be able to:

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

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

• Differentiate delirium tremens from other alcohol withdrawal syndromes.

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

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

• Apply DSM‐IV Diagnostic Criteria for Alcohol Withdrawal.

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

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

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

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

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

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

ATTITUDES

Hospitalists should be able to:

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

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

• Appreciate the indications for specialty consultations.

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

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

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

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

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

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

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

SYSTEM ORGANIZATION AND IMPROVEMENT

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

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

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

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

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

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

KNOWLEDGE

Hospitalists should be able to:

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

• Recognize the complications from substance use and dependency.

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

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

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

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

• Identify local trends in illicit drug use.

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

• Explain patient characteristics that on admission portend poor prognosis.

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

SKILLS

Hospitalists should be able to:

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

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

• Differentiate delirium tremens from other alcohol withdrawal syndromes.

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

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

• Apply DSM‐IV Diagnostic Criteria for Alcohol Withdrawal.

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

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

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

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

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

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

ATTITUDES

Hospitalists should be able to:

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

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

• Appreciate the indications for specialty consultations.

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

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

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

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

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

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

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

SYSTEM ORGANIZATION AND IMPROVEMENT

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

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

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

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

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

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

KNOWLEDGE

Hospitalists should be able to:

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

• Recognize the complications from substance use and dependency.

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

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

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

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

• Identify local trends in illicit drug use.

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

• Explain patient characteristics that on admission portend poor prognosis.

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

SKILLS

Hospitalists should be able to:

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

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

• Differentiate delirium tremens from other alcohol withdrawal syndromes.

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

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

• Apply DSM‐IV Diagnostic Criteria for Alcohol Withdrawal.

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

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

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

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

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

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

ATTITUDES

Hospitalists should be able to:

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

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

• Appreciate the indications for specialty consultations.

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

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

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

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

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

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

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

SYSTEM ORGANIZATION AND IMPROVEMENT

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

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

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

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

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

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

KNOWLEDGE

Hospitalists should be able to:

• Describe the complications related to hospitalization in the elderly.

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

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

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

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

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

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

SKILLS

Hospitalists should be able to:

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

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

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

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

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

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

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

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

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

• Recognize signs of potential elder abuse.

ATTITUDES

Hospitalists should be able to:

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

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

• Appreciate the risks and complications associated with restraint use.

• Appreciate the concept of transitional care.

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

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

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

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

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

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

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

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

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

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

KNOWLEDGE

Hospitalists should be able to:

• Describe the complications related to hospitalization in the elderly.

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

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

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

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

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

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

SKILLS

Hospitalists should be able to:

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

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

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

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

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

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

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

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

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

• Recognize signs of potential elder abuse.

ATTITUDES

Hospitalists should be able to:

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

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

• Appreciate the risks and complications associated with restraint use.

• Appreciate the concept of transitional care.

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

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

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

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

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

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

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

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

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

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

KNOWLEDGE

Hospitalists should be able to:

• Describe the complications related to hospitalization in the elderly.

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

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

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

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

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

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

SKILLS

Hospitalists should be able to:

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

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

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

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

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

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

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

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

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

• Recognize signs of potential elder abuse.

ATTITUDES

Hospitalists should be able to:

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

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

• Appreciate the risks and complications associated with restraint use.

• Appreciate the concept of transitional care.

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

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

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

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

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

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

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

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

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

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

KNOWLEDGE

Hospitalists should be able to:

• Define the concepts of equity and cost‐effectiveness.

• Identify patient populations at risk for inequitable health care.

• Recognize health resources that are prone to inequitable allocations.

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

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

• Discuss how stereotypes impact the allocation of health resources.

• Demonstrate how equity in health care is cost effective.

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

SKILLS

Hospitalists should be able to:

• Measure patient access to hospital resources.

• Incorporate equity concerns into cost‐effectiveness analysis.

• Triage patients to appropriate hospital resources.

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

• Monitor for equity in health care among hospitalized patients.

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

ATTITUDES

Hospitalists should be able to:

• Listen to the concerns of all patients.

• Advocate for every patient's needed health services.

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

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

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

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

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

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

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

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

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

KNOWLEDGE

Hospitalists should be able to:

• Define the concepts of equity and cost‐effectiveness.

• Identify patient populations at risk for inequitable health care.

• Recognize health resources that are prone to inequitable allocations.

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

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

• Discuss how stereotypes impact the allocation of health resources.

• Demonstrate how equity in health care is cost effective.

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

SKILLS

Hospitalists should be able to:

• Measure patient access to hospital resources.

• Incorporate equity concerns into cost‐effectiveness analysis.

• Triage patients to appropriate hospital resources.

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

• Monitor for equity in health care among hospitalized patients.

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

ATTITUDES

Hospitalists should be able to:

• Listen to the concerns of all patients.

• Advocate for every patient's needed health services.

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

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

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

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

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

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

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

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

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

KNOWLEDGE

Hospitalists should be able to:

• Define the concepts of equity and cost‐effectiveness.

• Identify patient populations at risk for inequitable health care.

• Recognize health resources that are prone to inequitable allocations.

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

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

• Discuss how stereotypes impact the allocation of health resources.

• Demonstrate how equity in health care is cost effective.

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

SKILLS

Hospitalists should be able to:

• Measure patient access to hospital resources.

• Incorporate equity concerns into cost‐effectiveness analysis.

• Triage patients to appropriate hospital resources.

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

• Monitor for equity in health care among hospitalized patients.

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

ATTITUDES

Hospitalists should be able to:

• Listen to the concerns of all patients.

• Advocate for every patient's needed health services.

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

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

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

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

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

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

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

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

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

CARDIOPULMONARY RESUSCITATION

KNOWLEDGE

Hospitalists should be able to:

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

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

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

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

• Explain basic life support (BLS) protocols.

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

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

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

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

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

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

SKILLS

Hospitalists should be able to:

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

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

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

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

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

• Continually reassess proper patient positioning during resuscitation.

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

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

• Maintain clinician safety with appropriate protective wear.

• Interpret cardiac rhythms and other diagnostic indicators.

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

ATTITUDES

Hospitalists should be able to:

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

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

• Rapidly respond to emergencies without distraction.

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

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

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

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

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

• Arrange for appropriate care transitions following successful resuscitation.

• Address family wishes regarding organ donation and autopsy.

ENDOTRACHEAL INTUBATION

KNOWLEDGE

Hospitalists should be able to:

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

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

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

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

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

• Describe and differentiate alternatives to endotracheal intubation.

SKILLS

Hospitalists should be able to:

• Identify patients for whom endotracheal intubation may be required.

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

• Select the appropriate laryngoscope blade for the individual patient.

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

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

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

• Request cricoid pressure and other maneuvers when indicated.

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

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

ATTITUDES

Hospitalists should be able to:

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

• Maintain high oxygen saturation prior to intubation whenever possible.

• Minimize patient trauma risk during intubations.

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

• Maintain clinician safety with appropriate protective wear.

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

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

MECHANICAL VENTILATION

KNOWLEDGE

Hospitalists should be able to:

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

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

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

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

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

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

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

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

SKILLS

Hospitalists should be able to:

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

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

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

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

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

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

ATTITUDES

Hospitalists should be able to:

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

• Obtain informed consent prior to non‐emergent intubations.

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

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

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

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

SYSTEM ORGANIZATION AND IMPROVEMENT FOR EMERGENCY PROCEDURES

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

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

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

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

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

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

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

CARDIOPULMONARY RESUSCITATION

KNOWLEDGE

Hospitalists should be able to:

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

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

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

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

• Explain basic life support (BLS) protocols.

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

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

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

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

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

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

SKILLS

Hospitalists should be able to:

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

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

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

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

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

• Continually reassess proper patient positioning during resuscitation.

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

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

• Maintain clinician safety with appropriate protective wear.

• Interpret cardiac rhythms and other diagnostic indicators.

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

ATTITUDES

Hospitalists should be able to:

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

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

• Rapidly respond to emergencies without distraction.

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

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

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

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

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

• Arrange for appropriate care transitions following successful resuscitation.

• Address family wishes regarding organ donation and autopsy.

ENDOTRACHEAL INTUBATION

KNOWLEDGE

Hospitalists should be able to:

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

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

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

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

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

• Describe and differentiate alternatives to endotracheal intubation.

SKILLS

Hospitalists should be able to:

• Identify patients for whom endotracheal intubation may be required.

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

• Select the appropriate laryngoscope blade for the individual patient.

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

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

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

• Request cricoid pressure and other maneuvers when indicated.

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

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

ATTITUDES

Hospitalists should be able to:

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

• Maintain high oxygen saturation prior to intubation whenever possible.

• Minimize patient trauma risk during intubations.

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

• Maintain clinician safety with appropriate protective wear.

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

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

MECHANICAL VENTILATION

KNOWLEDGE

Hospitalists should be able to:

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

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

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

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

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

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

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

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

SKILLS

Hospitalists should be able to:

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

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

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

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

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

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

ATTITUDES

Hospitalists should be able to:

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

• Obtain informed consent prior to non‐emergent intubations.

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

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

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

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

SYSTEM ORGANIZATION AND IMPROVEMENT FOR EMERGENCY PROCEDURES

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

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

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

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

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

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

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

CARDIOPULMONARY RESUSCITATION

KNOWLEDGE

Hospitalists should be able to:

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

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

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

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

• Explain basic life support (BLS) protocols.

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

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

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

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

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

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

SKILLS

Hospitalists should be able to:

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

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

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

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

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

• Continually reassess proper patient positioning during resuscitation.

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

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

• Maintain clinician safety with appropriate protective wear.

• Interpret cardiac rhythms and other diagnostic indicators.

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

ATTITUDES

Hospitalists should be able to:

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

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

• Rapidly respond to emergencies without distraction.

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

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

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

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

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

• Arrange for appropriate care transitions following successful resuscitation.

• Address family wishes regarding organ donation and autopsy.

ENDOTRACHEAL INTUBATION

KNOWLEDGE

Hospitalists should be able to:

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

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

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

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

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

• Describe and differentiate alternatives to endotracheal intubation.

SKILLS

Hospitalists should be able to:

• Identify patients for whom endotracheal intubation may be required.

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

• Select the appropriate laryngoscope blade for the individual patient.

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

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

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

• Request cricoid pressure and other maneuvers when indicated.

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

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

ATTITUDES

Hospitalists should be able to:

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

• Maintain high oxygen saturation prior to intubation whenever possible.

• Minimize patient trauma risk during intubations.

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

• Maintain clinician safety with appropriate protective wear.

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

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

MECHANICAL VENTILATION

KNOWLEDGE

Hospitalists should be able to:

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

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

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

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

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

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

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

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

SKILLS

Hospitalists should be able to:

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

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

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

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

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

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

ATTITUDES

Hospitalists should be able to:

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

• Obtain informed consent prior to non‐emergent intubations.

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

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

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

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

SYSTEM ORGANIZATION AND IMPROVEMENT FOR EMERGENCY PROCEDURES

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

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

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

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

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

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