Introduction

Sedation is used in conjunction with nonpharmacological interventions to minimize procedural pain and to provide decreased motion for successful completion of studies and interventions. Control of pain, anxiety, and memory can minimize negative psychological responses to treatment and lead to a higher success rate for diagnostic testing or therapy administration. Safe attainment of these goals requires careful preparation and clinical decision-making prior to the procedure, meticulous monitoring during the procedure, and skillful application of techniques to avoid or treat the complications of sedation. This may include the need to rescue patients from a deeper level of sedation than intended. While not all pediatric hospitalists will need to perform procedural sedation in their daily work, those who do must adhere to high standards of quality. With appropriate training and experience, pediatric hospitalists can safely provide a range of sedation services for pediatric patients.

Pediatric hospitalists should be able to:

• Discuss the goals of sedation, such as pain control, anxiolysis, amnesia, and motion control.
• Compare and contrast the definitions of minimal, moderate, and deep sedation, and general anesthesia, as established by the American Society of Anesthesiologists (ASA), American Academy of Pediatrics (AAP), and The Joint Commission (TJC).
• Define the ASA Physical Status Classification System and the Mallampati score to predict ease of endotracheal intubation.
• Discuss the pharmacology and effects of commonly used sedation medications (such as propofol, ketamine, midazolam, fentanyl, dexmedetomidine, nitrous oxide, and others), including planned effects and potential side effects.
• List commonly used single or combination medications and describe how each achieves the desired goal while minimizing the risk of complications and side effects.
• Discuss the establishment of a safe sedation plan that is developmentally tailored for children and adolescents of various ages.
• Discuss the proper level of monitoring and personnel needed to maximize the likelihood of a safe sedation outcome.
• Describe the use of nonpharmacologic interventions (such as bundling, glucose water pacifiers, presence of the family/caregivers, visual imagery, deep breathing, music, and others) as adjuncts to medications, to mitigate the perception of pain and anxiety.
• Discuss the inherent risks of administering sedating medications and apply the proper monitoring necessary to avoid and promptly recognize instability.
• Describe how age, disease process, and anatomy may increase the risk of sedation complications.
• Review indications for use of common reversal drugs, including anticipated results and duration of rescue effects.
• Identify the indications for consultation with subspecialists, such as anesthesiologists, intensivists, child life specialists, and others, when appropriate.

Pediatric hospitalists should be able to:

• Perform a pre-sedation evaluation, appropriately assigning ASA physical classification and Mallampati score, identifying anatomical risk factors, and delineating other patient-specific risks.
• Identify patients at higher risk for complications and efficiently refer to an anesthesiologist as appropriate.
• Review home medications and anticipate impact of these on the sedation plan.
• Communicate effectively with patients and the family/caregivers regarding the indications for, risks, benefits, and steps of sedation.
• Obtain informed consent from the family/caregivers prior to the sedation.
• Develop a sedation plan that is based on the pre-sedation evaluation and incorporates goals for the sedation and any patient-specific risks.
• Communicate effectively with the healthcare team before, during, and after the sedation to ensure accurate handoffs and safe, efficient care.
• Obtain intravenous access according to patient needs.
• Manage the airway at all levels of sedation, whether the level of sedation achieved was intended or unintended.
• Perform airway interventions and pediatric advanced life support as needed, in case of sedation complications.
• Identify side effects and complications of sedation and respond with appropriate actions.
• Select appropriate monitoring and correctly interpret monitor data.
• Identify when recovery criteria are met and initiate an appropriate discharge/transfer plan.

Pediatric hospitalists should be able to:

• Recognize the importance of effective collaboration with hospital staff and subspecialists to ensure coordinated planning and performance of sedation.
• Role model effective communication with patients and the family/caregivers about sedation indications, risks, benefits, and steps.

In order to improve efficiency and quality within their organizations, pediatric hospitalists should:

• Lead, coordinate, or participate in the development and implementation of cost-effective, safe, evidence-based procedures and policies for performance of sedation for children.
• Lead, coordinate, or participate in the development and implementation of a system for review of family/caregiver and healthcare provider satisfaction with sedation services.
• Collaborate with hospital staff and subspecialists to develop and implement management strategies for sedation.
• Lead, coordinate or participate in the establishment and maintenance of a process for obtaining sedation privileges, including demonstration of adequate knowledge and skill.
• Lead, coordinate or participate in the development and implementation of a system for review of the efficacy, efficiency and outcomes of procedures involving sedation.

Introduction

Sedation is used in conjunction with nonpharmacological interventions to minimize procedural pain and to provide decreased motion for successful completion of studies and interventions. Control of pain, anxiety, and memory can minimize negative psychological responses to treatment and lead to a higher success rate for diagnostic testing or therapy administration. Safe attainment of these goals requires careful preparation and clinical decision-making prior to the procedure, meticulous monitoring during the procedure, and skillful application of techniques to avoid or treat the complications of sedation. This may include the need to rescue patients from a deeper level of sedation than intended. While not all pediatric hospitalists will need to perform procedural sedation in their daily work, those who do must adhere to high standards of quality. With appropriate training and experience, pediatric hospitalists can safely provide a range of sedation services for pediatric patients.

Pediatric hospitalists should be able to:

• Discuss the goals of sedation, such as pain control, anxiolysis, amnesia, and motion control.
• Compare and contrast the definitions of minimal, moderate, and deep sedation, and general anesthesia, as established by the American Society of Anesthesiologists (ASA), American Academy of Pediatrics (AAP), and The Joint Commission (TJC).
• Define the ASA Physical Status Classification System and the Mallampati score to predict ease of endotracheal intubation.
• Discuss the pharmacology and effects of commonly used sedation medications (such as propofol, ketamine, midazolam, fentanyl, dexmedetomidine, nitrous oxide, and others), including planned effects and potential side effects.
• List commonly used single or combination medications and describe how each achieves the desired goal while minimizing the risk of complications and side effects.
• Discuss the establishment of a safe sedation plan that is developmentally tailored for children and adolescents of various ages.
• Discuss the proper level of monitoring and personnel needed to maximize the likelihood of a safe sedation outcome.
• Describe the use of nonpharmacologic interventions (such as bundling, glucose water pacifiers, presence of the family/caregivers, visual imagery, deep breathing, music, and others) as adjuncts to medications, to mitigate the perception of pain and anxiety.
• Discuss the inherent risks of administering sedating medications and apply the proper monitoring necessary to avoid and promptly recognize instability.
• Describe how age, disease process, and anatomy may increase the risk of sedation complications.
• Review indications for use of common reversal drugs, including anticipated results and duration of rescue effects.
• Identify the indications for consultation with subspecialists, such as anesthesiologists, intensivists, child life specialists, and others, when appropriate.

Pediatric hospitalists should be able to:

• Perform a pre-sedation evaluation, appropriately assigning ASA physical classification and Mallampati score, identifying anatomical risk factors, and delineating other patient-specific risks.
• Identify patients at higher risk for complications and efficiently refer to an anesthesiologist as appropriate.
• Review home medications and anticipate impact of these on the sedation plan.
• Communicate effectively with patients and the family/caregivers regarding the indications for, risks, benefits, and steps of sedation.
• Obtain informed consent from the family/caregivers prior to the sedation.
• Develop a sedation plan that is based on the pre-sedation evaluation and incorporates goals for the sedation and any patient-specific risks.
• Communicate effectively with the healthcare team before, during, and after the sedation to ensure accurate handoffs and safe, efficient care.
• Obtain intravenous access according to patient needs.
• Manage the airway at all levels of sedation, whether the level of sedation achieved was intended or unintended.
• Perform airway interventions and pediatric advanced life support as needed, in case of sedation complications.
• Identify side effects and complications of sedation and respond with appropriate actions.
• Select appropriate monitoring and correctly interpret monitor data.
• Identify when recovery criteria are met and initiate an appropriate discharge/transfer plan.

Pediatric hospitalists should be able to:

• Recognize the importance of effective collaboration with hospital staff and subspecialists to ensure coordinated planning and performance of sedation.
• Role model effective communication with patients and the family/caregivers about sedation indications, risks, benefits, and steps.

In order to improve efficiency and quality within their organizations, pediatric hospitalists should:

• Lead, coordinate, or participate in the development and implementation of cost-effective, safe, evidence-based procedures and policies for performance of sedation for children.
• Lead, coordinate, or participate in the development and implementation of a system for review of family/caregiver and healthcare provider satisfaction with sedation services.
• Collaborate with hospital staff and subspecialists to develop and implement management strategies for sedation.
• Lead, coordinate or participate in the establishment and maintenance of a process for obtaining sedation privileges, including demonstration of adequate knowledge and skill.
• Lead, coordinate or participate in the development and implementation of a system for review of the efficacy, efficiency and outcomes of procedures involving sedation.

Introduction

Sedation is used in conjunction with nonpharmacological interventions to minimize procedural pain and to provide decreased motion for successful completion of studies and interventions. Control of pain, anxiety, and memory can minimize negative psychological responses to treatment and lead to a higher success rate for diagnostic testing or therapy administration. Safe attainment of these goals requires careful preparation and clinical decision-making prior to the procedure, meticulous monitoring during the procedure, and skillful application of techniques to avoid or treat the complications of sedation. This may include the need to rescue patients from a deeper level of sedation than intended. While not all pediatric hospitalists will need to perform procedural sedation in their daily work, those who do must adhere to high standards of quality. With appropriate training and experience, pediatric hospitalists can safely provide a range of sedation services for pediatric patients.

Pediatric hospitalists should be able to:

• Discuss the goals of sedation, such as pain control, anxiolysis, amnesia, and motion control.
• Compare and contrast the definitions of minimal, moderate, and deep sedation, and general anesthesia, as established by the American Society of Anesthesiologists (ASA), American Academy of Pediatrics (AAP), and The Joint Commission (TJC).
• Define the ASA Physical Status Classification System and the Mallampati score to predict ease of endotracheal intubation.
• Discuss the pharmacology and effects of commonly used sedation medications (such as propofol, ketamine, midazolam, fentanyl, dexmedetomidine, nitrous oxide, and others), including planned effects and potential side effects.
• List commonly used single or combination medications and describe how each achieves the desired goal while minimizing the risk of complications and side effects.
• Discuss the establishment of a safe sedation plan that is developmentally tailored for children and adolescents of various ages.
• Discuss the proper level of monitoring and personnel needed to maximize the likelihood of a safe sedation outcome.
• Describe the use of nonpharmacologic interventions (such as bundling, glucose water pacifiers, presence of the family/caregivers, visual imagery, deep breathing, music, and others) as adjuncts to medications, to mitigate the perception of pain and anxiety.
• Discuss the inherent risks of administering sedating medications and apply the proper monitoring necessary to avoid and promptly recognize instability.
• Describe how age, disease process, and anatomy may increase the risk of sedation complications.
• Review indications for use of common reversal drugs, including anticipated results and duration of rescue effects.
• Identify the indications for consultation with subspecialists, such as anesthesiologists, intensivists, child life specialists, and others, when appropriate.

Pediatric hospitalists should be able to:

• Perform a pre-sedation evaluation, appropriately assigning ASA physical classification and Mallampati score, identifying anatomical risk factors, and delineating other patient-specific risks.
• Identify patients at higher risk for complications and efficiently refer to an anesthesiologist as appropriate.
• Review home medications and anticipate impact of these on the sedation plan.
• Communicate effectively with patients and the family/caregivers regarding the indications for, risks, benefits, and steps of sedation.
• Obtain informed consent from the family/caregivers prior to the sedation.
• Develop a sedation plan that is based on the pre-sedation evaluation and incorporates goals for the sedation and any patient-specific risks.
• Communicate effectively with the healthcare team before, during, and after the sedation to ensure accurate handoffs and safe, efficient care.
• Obtain intravenous access according to patient needs.
• Manage the airway at all levels of sedation, whether the level of sedation achieved was intended or unintended.
• Perform airway interventions and pediatric advanced life support as needed, in case of sedation complications.
• Identify side effects and complications of sedation and respond with appropriate actions.
• Select appropriate monitoring and correctly interpret monitor data.
• Identify when recovery criteria are met and initiate an appropriate discharge/transfer plan.

Pediatric hospitalists should be able to:

• Recognize the importance of effective collaboration with hospital staff and subspecialists to ensure coordinated planning and performance of sedation.
• Role model effective communication with patients and the family/caregivers about sedation indications, risks, benefits, and steps.

In order to improve efficiency and quality within their organizations, pediatric hospitalists should:

• Lead, coordinate, or participate in the development and implementation of cost-effective, safe, evidence-based procedures and policies for performance of sedation for children.
• Lead, coordinate, or participate in the development and implementation of a system for review of family/caregiver and healthcare provider satisfaction with sedation services.
• Collaborate with hospital staff and subspecialists to develop and implement management strategies for sedation.
• Lead, coordinate or participate in the establishment and maintenance of a process for obtaining sedation privileges, including demonstration of adequate knowledge and skill.
• Lead, coordinate or participate in the development and implementation of a system for review of the efficacy, efficiency and outcomes of procedures involving sedation.

Introduction

Pediatric hospitalists take a generalist and preventive care approach to patient care in the inpatient setting, focusing on the provision of routine health care maintenance and the prevention of hospital-acquired conditions (HACs). Hospitalized children, particularly those with barriers to consistent access to health care, deserve a thorough review of items related to general well-child and preventive care, regardless of the reason for admission. Furthermore, safety research in pediatrics has consistently shown that hospitalized children, especially those with high medical complexity, are at great risk for adverse events. In this context, pediatric hospitalists in all practice settings must make efforts to eliminate unnecessary exposures and monitor for and prevent HACs.

Pediatric hospitalists should be able to:

• Summarize the current recommended vaccine schedules for pediatric patients, the indications, contraindications, and side effects for each vaccine.
• Explain typical patterns for growth and development of secondary sex characteristics and describe how to utilize growth charts and the sexual maturity rating scale to assess age-appropriate changes.
• List the developmental milestones for children of different ages and describe the components of commonly utilized developmental screening tools.
• List the elements of the HEADDS exam for adolescents.
• Explain the value of assessing for preventive health needs during the hospital encounter, attending to socioeconomic factors that may limit opportunities for these assessments in the ambulatory setting, such as access to healthcare.
• Discuss the impact of oral health on children with and without chronic medical conditions.
• Define the phrase hospital-acquired condition (HAC).
• List the common HACs affecting hospitalized children, such as central line associated bloodstream infections, catheter associated urinary tract infections, pressure injuries and wound infections, and surgical site infections.
• Describe proven methods to prevent HACs, with emphasis on the need for multiple grouped interventions (such as bundled care, clinical pathways, checklists, and others) to produce more complete and sustained change.
• Identify the HACs routinely monitored by their hospital safety teams.

Pediatric hospitalists should be able to:

• Complete a comprehensive physical exam, including anthropometrics, breast exam if applicable, and a genitourinary exam, to assess for appropriate growth and development of secondary sex characteristics.
• Perform and respond to needs identified by preventive care assessments, including:

–Immunization history, accessing immunization registries if available local records are incomplete

–HEADSS exam for adolescents

–Screening for: Developmental and behavioral needs; oral health; toxic exposure; growth including inadequate or excessive weight and obesity.

• Coordinate care with an interdisciplinary team to identify and address needs of patients with depression and/or suicidality.
• Coordinate care with an interdisciplinary team to identify and address needs of patients and the family/caregivers with at risk social determinants of health, such as food insecurity, homelessness, and others.
• Refer patients and the family/caregivers to appropriate institutional and community resources to address identified gaps in health care maintenance.
• Identify patients at risk for HACs upon initial assessment, taking the clinical presentation and level of medical complexity into account.
• Use evidence-based, bundled care practices to reduce or prevent HACs.
• Order appropriate interventions for the prevention of HACs and other clinical conditions, including:

–Central line infections

–Skin breakdown and pressure injuries

–Deep venous thromboses

–Gastritis, esophagitis, and related gastrointestinal conditions

–Deconditioning

• Order appropriate interventions to support oral hygiene and ocular health.
• Assess the ongoing need for intravenous access, urinary catheters, and other tubes and lines when applicable, promoting removal as soon as they are no longer medically necessary.
• Evaluate the necessity of commonly ordered interventions in order to decrease or eliminate unnecessary exposures and risks for patients.
• Order vaccinations for patients where appropriate, indicated, and available, including annual flu vaccine.

Pediatric hospitalists should be able to:

• Appreciate the importance of reviewing the general heath care of a child during hospitalization.
• Realize the value of communicating directly with a patient’s primary care provider regarding healthcare maintenance concerns found and/or addressed during hospitalization.
• Maintain awareness of the risks of hospitalization, as well as risk management strategies, for pediatric patients.
• Recognize the importance of participating in care collaboratives to reduce harm beyond the immediate care setting.
• Appreciate the value of submitting patient safety data to appropriate sources for benchmarking in order to support overall preventive care strategies.

In order to improve efficiency and quality within their organizations, pediatric hospitalists should:

• Collaborate with hospital information systems to ensure accurate representation of relevant healthcare maintenance data in the electronic health record, such as immunization records, growth charts, and contact information for primary care providers.
• Advocate for access to primary care providers and community resources for children with health care maintenance gaps and social determinants of health risks identified during hospitalization.
• Collaborate with hospital administrators to ensure existence of referral processes for local and national developmental services resources.
• Lead, coordinate, or participate in the development of effective surveillance tools and other quality improvement efforts to identify, prevent, or reduce the occurrence of HACs.
• Collaborate with hospital quality and safety teams to collect and share institutional data on HACs.

Introduction

Pediatric hospitalists take a generalist and preventive care approach to patient care in the inpatient setting, focusing on the provision of routine health care maintenance and the prevention of hospital-acquired conditions (HACs). Hospitalized children, particularly those with barriers to consistent access to health care, deserve a thorough review of items related to general well-child and preventive care, regardless of the reason for admission. Furthermore, safety research in pediatrics has consistently shown that hospitalized children, especially those with high medical complexity, are at great risk for adverse events. In this context, pediatric hospitalists in all practice settings must make efforts to eliminate unnecessary exposures and monitor for and prevent HACs.

Pediatric hospitalists should be able to:

• Summarize the current recommended vaccine schedules for pediatric patients, the indications, contraindications, and side effects for each vaccine.
• Explain typical patterns for growth and development of secondary sex characteristics and describe how to utilize growth charts and the sexual maturity rating scale to assess age-appropriate changes.
• List the developmental milestones for children of different ages and describe the components of commonly utilized developmental screening tools.
• List the elements of the HEADDS exam for adolescents.
• Explain the value of assessing for preventive health needs during the hospital encounter, attending to socioeconomic factors that may limit opportunities for these assessments in the ambulatory setting, such as access to healthcare.
• Discuss the impact of oral health on children with and without chronic medical conditions.
• Define the phrase hospital-acquired condition (HAC).
• List the common HACs affecting hospitalized children, such as central line associated bloodstream infections, catheter associated urinary tract infections, pressure injuries and wound infections, and surgical site infections.
• Describe proven methods to prevent HACs, with emphasis on the need for multiple grouped interventions (such as bundled care, clinical pathways, checklists, and others) to produce more complete and sustained change.
• Identify the HACs routinely monitored by their hospital safety teams.

Pediatric hospitalists should be able to:

• Complete a comprehensive physical exam, including anthropometrics, breast exam if applicable, and a genitourinary exam, to assess for appropriate growth and development of secondary sex characteristics.
• Perform and respond to needs identified by preventive care assessments, including:

–Immunization history, accessing immunization registries if available local records are incomplete

–HEADSS exam for adolescents

–Screening for: Developmental and behavioral needs; oral health; toxic exposure; growth including inadequate or excessive weight and obesity.

• Coordinate care with an interdisciplinary team to identify and address needs of patients with depression and/or suicidality.
• Coordinate care with an interdisciplinary team to identify and address needs of patients and the family/caregivers with at risk social determinants of health, such as food insecurity, homelessness, and others.
• Refer patients and the family/caregivers to appropriate institutional and community resources to address identified gaps in health care maintenance.
• Identify patients at risk for HACs upon initial assessment, taking the clinical presentation and level of medical complexity into account.
• Use evidence-based, bundled care practices to reduce or prevent HACs.
• Order appropriate interventions for the prevention of HACs and other clinical conditions, including:

–Central line infections

–Skin breakdown and pressure injuries

–Deep venous thromboses

–Gastritis, esophagitis, and related gastrointestinal conditions

–Deconditioning

• Order appropriate interventions to support oral hygiene and ocular health.
• Assess the ongoing need for intravenous access, urinary catheters, and other tubes and lines when applicable, promoting removal as soon as they are no longer medically necessary.
• Evaluate the necessity of commonly ordered interventions in order to decrease or eliminate unnecessary exposures and risks for patients.
• Order vaccinations for patients where appropriate, indicated, and available, including annual flu vaccine.

Pediatric hospitalists should be able to:

• Appreciate the importance of reviewing the general heath care of a child during hospitalization.
• Realize the value of communicating directly with a patient’s primary care provider regarding healthcare maintenance concerns found and/or addressed during hospitalization.
• Maintain awareness of the risks of hospitalization, as well as risk management strategies, for pediatric patients.
• Recognize the importance of participating in care collaboratives to reduce harm beyond the immediate care setting.
• Appreciate the value of submitting patient safety data to appropriate sources for benchmarking in order to support overall preventive care strategies.

In order to improve efficiency and quality within their organizations, pediatric hospitalists should:

• Collaborate with hospital information systems to ensure accurate representation of relevant healthcare maintenance data in the electronic health record, such as immunization records, growth charts, and contact information for primary care providers.
• Advocate for access to primary care providers and community resources for children with health care maintenance gaps and social determinants of health risks identified during hospitalization.
• Collaborate with hospital administrators to ensure existence of referral processes for local and national developmental services resources.
• Lead, coordinate, or participate in the development of effective surveillance tools and other quality improvement efforts to identify, prevent, or reduce the occurrence of HACs.
• Collaborate with hospital quality and safety teams to collect and share institutional data on HACs.

Introduction

Pediatric hospitalists take a generalist and preventive care approach to patient care in the inpatient setting, focusing on the provision of routine health care maintenance and the prevention of hospital-acquired conditions (HACs). Hospitalized children, particularly those with barriers to consistent access to health care, deserve a thorough review of items related to general well-child and preventive care, regardless of the reason for admission. Furthermore, safety research in pediatrics has consistently shown that hospitalized children, especially those with high medical complexity, are at great risk for adverse events. In this context, pediatric hospitalists in all practice settings must make efforts to eliminate unnecessary exposures and monitor for and prevent HACs.

Pediatric hospitalists should be able to:

• Summarize the current recommended vaccine schedules for pediatric patients, the indications, contraindications, and side effects for each vaccine.
• Explain typical patterns for growth and development of secondary sex characteristics and describe how to utilize growth charts and the sexual maturity rating scale to assess age-appropriate changes.
• List the developmental milestones for children of different ages and describe the components of commonly utilized developmental screening tools.
• List the elements of the HEADDS exam for adolescents.
• Explain the value of assessing for preventive health needs during the hospital encounter, attending to socioeconomic factors that may limit opportunities for these assessments in the ambulatory setting, such as access to healthcare.
• Discuss the impact of oral health on children with and without chronic medical conditions.
• Define the phrase hospital-acquired condition (HAC).
• List the common HACs affecting hospitalized children, such as central line associated bloodstream infections, catheter associated urinary tract infections, pressure injuries and wound infections, and surgical site infections.
• Describe proven methods to prevent HACs, with emphasis on the need for multiple grouped interventions (such as bundled care, clinical pathways, checklists, and others) to produce more complete and sustained change.
• Identify the HACs routinely monitored by their hospital safety teams.

Pediatric hospitalists should be able to:

• Complete a comprehensive physical exam, including anthropometrics, breast exam if applicable, and a genitourinary exam, to assess for appropriate growth and development of secondary sex characteristics.
• Perform and respond to needs identified by preventive care assessments, including:

–Immunization history, accessing immunization registries if available local records are incomplete

–HEADSS exam for adolescents

–Screening for: Developmental and behavioral needs; oral health; toxic exposure; growth including inadequate or excessive weight and obesity.

• Coordinate care with an interdisciplinary team to identify and address needs of patients with depression and/or suicidality.
• Coordinate care with an interdisciplinary team to identify and address needs of patients and the family/caregivers with at risk social determinants of health, such as food insecurity, homelessness, and others.
• Refer patients and the family/caregivers to appropriate institutional and community resources to address identified gaps in health care maintenance.
• Identify patients at risk for HACs upon initial assessment, taking the clinical presentation and level of medical complexity into account.
• Use evidence-based, bundled care practices to reduce or prevent HACs.
• Order appropriate interventions for the prevention of HACs and other clinical conditions, including:

–Central line infections

–Skin breakdown and pressure injuries

–Deep venous thromboses

–Gastritis, esophagitis, and related gastrointestinal conditions

–Deconditioning

• Order appropriate interventions to support oral hygiene and ocular health.
• Assess the ongoing need for intravenous access, urinary catheters, and other tubes and lines when applicable, promoting removal as soon as they are no longer medically necessary.
• Evaluate the necessity of commonly ordered interventions in order to decrease or eliminate unnecessary exposures and risks for patients.
• Order vaccinations for patients where appropriate, indicated, and available, including annual flu vaccine.

Pediatric hospitalists should be able to:

• Appreciate the importance of reviewing the general heath care of a child during hospitalization.
• Realize the value of communicating directly with a patient’s primary care provider regarding healthcare maintenance concerns found and/or addressed during hospitalization.
• Maintain awareness of the risks of hospitalization, as well as risk management strategies, for pediatric patients.
• Recognize the importance of participating in care collaboratives to reduce harm beyond the immediate care setting.
• Appreciate the value of submitting patient safety data to appropriate sources for benchmarking in order to support overall preventive care strategies.

In order to improve efficiency and quality within their organizations, pediatric hospitalists should:

• Collaborate with hospital information systems to ensure accurate representation of relevant healthcare maintenance data in the electronic health record, such as immunization records, growth charts, and contact information for primary care providers.
• Advocate for access to primary care providers and community resources for children with health care maintenance gaps and social determinants of health risks identified during hospitalization.
• Collaborate with hospital administrators to ensure existence of referral processes for local and national developmental services resources.
• Lead, coordinate, or participate in the development of effective surveillance tools and other quality improvement efforts to identify, prevent, or reduce the occurrence of HACs.
• Collaborate with hospital quality and safety teams to collect and share institutional data on HACs.

Introduction

Pediatric hospitalists are increasingly involved in the peri-procedural care of patients having surgical interventions performed in the operating room or other procedure units, including interventional radiology. Rendering this care requires specific expertise, including skill in communication and collaboration with hospital staff, anesthesiologists, proceduralists, surgeons, and other subspecialists. While not all pediatric hospitalists care for patients in the peri-procedural period, pediatric hospitalists should be knowledgeable and skillful in the provision and coordination of peri-procedural care when local demands dictate.

Pediatric hospitalists should be able to:

• Describe short- and long-term goals to optimize surgical outcomes, including attention to comorbidities, anemia, fluid management, anticoagulation, and pulmonary optimization.
• Describe the essential role of child life in patient and family understanding of procedures, preparation, and coping strategies.
• Define the American Society of Anesthesiology (ASA) Physical Status Classification System and the Mallampati score that predict difficulty of endotracheal intubation.
• Discuss commonly used anesthetic agents and their side effects such as propofol, ketamine, midazolam, dexmedetomidine, and fentanyl.
• Describe risk factors and mitigation strategies, dependent on type of surgery and patient population, for surgical site infection (SSI) prevention, including skin/hair preparation and bacterial surveillance screening.
• List venous thromboembolism (VTE) risk factors and prevention measures.
• Review how use of physical and occupational therapy to promote early mobilization post-procedure may reduce incidence of pressure ulcers and length of stay.
• Explain key principles of early multimodal pain management, including key neurological pathways, early treatment of pain, and patient variability in pain thresholds.
• Compare and contrast indications for and side effects of commonly used peri-procedural analgesia agents, including acetaminophen, nonsteroidal anti-inflammatory drugs, opioids, gamma-aminobutyric acid (GABA) agents, and anxiolytics.
• Describe nonpharmacologic approaches to pain reduction, including age-appropriate distraction, massage, and the use of child life specialists when available.
• Describe adjuvant approaches to decrease opioid use in the inpatient setting and at discharge, including limiting quantity of opioids prescribed.
• Discuss patient risk factors for pain that may be difficult to control, such as history of substance abuse and others.
• Review indications, dosing parameters, and safety concerns for epidural and intravenous patient-controlled analgesia (PCA), including recommendations for basal and bolus rates, according to local context.
• Describe the different types, indications for use, natural course, and removal of temporary surgical tubes and drains, such as chest tubes, Penrose drains, closed suction drains (Jackson-Pratt, Blake, Hemovac), and others.
• Explain the basic function of the three-chamber collecting system used for chest tubes.
• Compare and contrast a suction chamber device with wall suction with a device on water seal.
• Discuss common techniques for wound care treatment, including different types of topical dressings and indications for negative pressure wound therapy.
• Describe the overall natural history of wound healing and strategies to hasten wound healing, including optimal nutrition, vitamin supplementation, and positioning.
• Review the consequences of post-procedural cytokine release, attending to potential impact on body temperature and blood inflammatory markers.
• Describe indications, contraindications, and complications for incision and drainage of cutaneous abscesses.
• Discuss appropriate empiric antibiotics for abscess management based on the local antibiogram and patient-specific factors.
• Explain the importance of antibiotic stewardship in selection of peri-procedural antibiotics.

Pediatric hospitalists should be able to:

• Demonstrate proficiency in interpreting an anesthesiology record to identify intraoperative receipt of analgesia, fluids, and blood products.
• Identify post-extubation airway issues, including stridor, and provide management as necessary.
• Demonstrate effective management of peri-procedural fluids, antibiotics, and pediatric medication dosing.
• Develop a management plan for post-anesthesia nausea and vomiting.
• Identify and treat post-procedural aspiration pneumonitis when clinically evident.
• Assess signs and symptoms to appropriately advance post-procedure diet.
• Identify abnormal progression of feeding advancement and investigate and treat causes, including prolonged ileus, obstruction, and constipation.
• Assess pain using validated, age-appropriate, and developmentally appropriate pain scales, including adaptive scales for nonverbal patients.
• Apply risk criteria for initiation of mechanical and pharmacologic VTE prophylaxis in collaboration with hematologic, surgical, and nursing colleagues.
• Direct a cost-effective and evidence-based evaluation of post-procedural fever.
• Identify signs of inappropriate positioning or complications of surgical tubes and drains and provide initial management in collaboration with the procedural team.
• Utilize optimal technique in assisting with chest tube removal, in collaboration with the procedural team per local context.
• Identify possible complications of chest tube removal and provide management, in collaboration with the procedural team per local context.
• Evaluate and accurately describe surgical wounds, pressure ulcers, and burns, including location, stage or tissue depth, and presence of exudate, necrotic tissue, or granulation tissue.
• Interpret common signs of surgical wound complications, such as infection and wound dehiscence.
• Assess fresh ostomy and fistula sites for integrity and identify concerning features that trigger timely surgical consultation.
• Diagnose superficial (early) post-procedural infection during index hospitalization, as well as deep (late) post-procedural infection for patients admitted with fever.
• Demonstrate proficiency in conducting a physical examination of skin and soft tissue infections to determine presence of cutaneous abscess and need for incision and drainage.
• Demonstrate proficiency in incision and drainage of simple cutaneous abscesses, including pre-procedural patient counseling, obtaining informed consent, and administering patient-appropriate analgesia, anxiolysis, and sedation.
• Engage surgical consultants efficiently when indicated, such as for assessment of complex abscesses, abscesses in high-risk locations, and others.
• Provide post-procedural management following abscess incision and drainage, including management of packing or surgical drains, wound care, and anticipatory guidance.

Pediatric hospitalists should be able to:

• Recognize the importance of collaborating with patients, the family/caregivers, hospital staff, anesthesiologists, other subspecialists, and primary care providers, to ensure coordinated hospital care for children during the peri-procedural period.
• Role model effective communication with patients and the family/caregivers using developmentally appropriate and family-centered language to ensure understanding and encourage participation in decision-making.
• Appreciate the importance of collaboration with nursing, child life, pain team, and/or psychology/psychiatry colleagues, to minimize patient anxiety and peri-procedural pain.
• Exemplify collaborative practice with wound care teams and available local resources, such as nursing, surgical subspecialists, dermatology, and burn units, to ensure optimal wound care during the hospitalization and a comprehensive wound care plan at time of discharge.

In order to improve efficiency and quality within their organizations, pediatric hospitalists should:

• Lead, coordinate, or participate in the development and implementation of safe, cost-effective, evidence-based care pathways to standardize peri-procedural management.
• Lead, coordinate, or participate in development of standardized handoff systems for optimal transition of care between anesthesia, surgery, and pediatric hospital medicine.
• Work with hospital staff and surgical subspecialists to coordinate ongoing educational opportunities to improve the skill set of healthcare providers in peri-procedural care.

Introduction

Pediatric hospitalists are increasingly involved in the peri-procedural care of patients having surgical interventions performed in the operating room or other procedure units, including interventional radiology. Rendering this care requires specific expertise, including skill in communication and collaboration with hospital staff, anesthesiologists, proceduralists, surgeons, and other subspecialists. While not all pediatric hospitalists care for patients in the peri-procedural period, pediatric hospitalists should be knowledgeable and skillful in the provision and coordination of peri-procedural care when local demands dictate.

Pediatric hospitalists should be able to:

• Describe short- and long-term goals to optimize surgical outcomes, including attention to comorbidities, anemia, fluid management, anticoagulation, and pulmonary optimization.
• Describe the essential role of child life in patient and family understanding of procedures, preparation, and coping strategies.
• Define the American Society of Anesthesiology (ASA) Physical Status Classification System and the Mallampati score that predict difficulty of endotracheal intubation.
• Discuss commonly used anesthetic agents and their side effects such as propofol, ketamine, midazolam, dexmedetomidine, and fentanyl.
• Describe risk factors and mitigation strategies, dependent on type of surgery and patient population, for surgical site infection (SSI) prevention, including skin/hair preparation and bacterial surveillance screening.
• List venous thromboembolism (VTE) risk factors and prevention measures.
• Review how use of physical and occupational therapy to promote early mobilization post-procedure may reduce incidence of pressure ulcers and length of stay.
• Explain key principles of early multimodal pain management, including key neurological pathways, early treatment of pain, and patient variability in pain thresholds.
• Compare and contrast indications for and side effects of commonly used peri-procedural analgesia agents, including acetaminophen, nonsteroidal anti-inflammatory drugs, opioids, gamma-aminobutyric acid (GABA) agents, and anxiolytics.
• Describe nonpharmacologic approaches to pain reduction, including age-appropriate distraction, massage, and the use of child life specialists when available.
• Describe adjuvant approaches to decrease opioid use in the inpatient setting and at discharge, including limiting quantity of opioids prescribed.
• Discuss patient risk factors for pain that may be difficult to control, such as history of substance abuse and others.
• Review indications, dosing parameters, and safety concerns for epidural and intravenous patient-controlled analgesia (PCA), including recommendations for basal and bolus rates, according to local context.
• Describe the different types, indications for use, natural course, and removal of temporary surgical tubes and drains, such as chest tubes, Penrose drains, closed suction drains (Jackson-Pratt, Blake, Hemovac), and others.
• Explain the basic function of the three-chamber collecting system used for chest tubes.
• Compare and contrast a suction chamber device with wall suction with a device on water seal.
• Discuss common techniques for wound care treatment, including different types of topical dressings and indications for negative pressure wound therapy.
• Describe the overall natural history of wound healing and strategies to hasten wound healing, including optimal nutrition, vitamin supplementation, and positioning.
• Review the consequences of post-procedural cytokine release, attending to potential impact on body temperature and blood inflammatory markers.
• Describe indications, contraindications, and complications for incision and drainage of cutaneous abscesses.
• Discuss appropriate empiric antibiotics for abscess management based on the local antibiogram and patient-specific factors.
• Explain the importance of antibiotic stewardship in selection of peri-procedural antibiotics.

Pediatric hospitalists should be able to:

• Demonstrate proficiency in interpreting an anesthesiology record to identify intraoperative receipt of analgesia, fluids, and blood products.
• Identify post-extubation airway issues, including stridor, and provide management as necessary.
• Demonstrate effective management of peri-procedural fluids, antibiotics, and pediatric medication dosing.
• Develop a management plan for post-anesthesia nausea and vomiting.
• Identify and treat post-procedural aspiration pneumonitis when clinically evident.
• Assess signs and symptoms to appropriately advance post-procedure diet.
• Identify abnormal progression of feeding advancement and investigate and treat causes, including prolonged ileus, obstruction, and constipation.
• Assess pain using validated, age-appropriate, and developmentally appropriate pain scales, including adaptive scales for nonverbal patients.
• Apply risk criteria for initiation of mechanical and pharmacologic VTE prophylaxis in collaboration with hematologic, surgical, and nursing colleagues.
• Direct a cost-effective and evidence-based evaluation of post-procedural fever.
• Identify signs of inappropriate positioning or complications of surgical tubes and drains and provide initial management in collaboration with the procedural team.
• Utilize optimal technique in assisting with chest tube removal, in collaboration with the procedural team per local context.
• Identify possible complications of chest tube removal and provide management, in collaboration with the procedural team per local context.
• Evaluate and accurately describe surgical wounds, pressure ulcers, and burns, including location, stage or tissue depth, and presence of exudate, necrotic tissue, or granulation tissue.
• Interpret common signs of surgical wound complications, such as infection and wound dehiscence.
• Assess fresh ostomy and fistula sites for integrity and identify concerning features that trigger timely surgical consultation.
• Diagnose superficial (early) post-procedural infection during index hospitalization, as well as deep (late) post-procedural infection for patients admitted with fever.
• Demonstrate proficiency in conducting a physical examination of skin and soft tissue infections to determine presence of cutaneous abscess and need for incision and drainage.
• Demonstrate proficiency in incision and drainage of simple cutaneous abscesses, including pre-procedural patient counseling, obtaining informed consent, and administering patient-appropriate analgesia, anxiolysis, and sedation.
• Engage surgical consultants efficiently when indicated, such as for assessment of complex abscesses, abscesses in high-risk locations, and others.
• Provide post-procedural management following abscess incision and drainage, including management of packing or surgical drains, wound care, and anticipatory guidance.

Pediatric hospitalists should be able to:

• Recognize the importance of collaborating with patients, the family/caregivers, hospital staff, anesthesiologists, other subspecialists, and primary care providers, to ensure coordinated hospital care for children during the peri-procedural period.
• Role model effective communication with patients and the family/caregivers using developmentally appropriate and family-centered language to ensure understanding and encourage participation in decision-making.
• Appreciate the importance of collaboration with nursing, child life, pain team, and/or psychology/psychiatry colleagues, to minimize patient anxiety and peri-procedural pain.
• Exemplify collaborative practice with wound care teams and available local resources, such as nursing, surgical subspecialists, dermatology, and burn units, to ensure optimal wound care during the hospitalization and a comprehensive wound care plan at time of discharge.

In order to improve efficiency and quality within their organizations, pediatric hospitalists should:

• Lead, coordinate, or participate in the development and implementation of safe, cost-effective, evidence-based care pathways to standardize peri-procedural management.
• Lead, coordinate, or participate in development of standardized handoff systems for optimal transition of care between anesthesia, surgery, and pediatric hospital medicine.
• Work with hospital staff and surgical subspecialists to coordinate ongoing educational opportunities to improve the skill set of healthcare providers in peri-procedural care.

Introduction

Pediatric hospitalists are increasingly involved in the peri-procedural care of patients having surgical interventions performed in the operating room or other procedure units, including interventional radiology. Rendering this care requires specific expertise, including skill in communication and collaboration with hospital staff, anesthesiologists, proceduralists, surgeons, and other subspecialists. While not all pediatric hospitalists care for patients in the peri-procedural period, pediatric hospitalists should be knowledgeable and skillful in the provision and coordination of peri-procedural care when local demands dictate.

Pediatric hospitalists should be able to:

• Describe short- and long-term goals to optimize surgical outcomes, including attention to comorbidities, anemia, fluid management, anticoagulation, and pulmonary optimization.
• Describe the essential role of child life in patient and family understanding of procedures, preparation, and coping strategies.
• Define the American Society of Anesthesiology (ASA) Physical Status Classification System and the Mallampati score that predict difficulty of endotracheal intubation.
• Discuss commonly used anesthetic agents and their side effects such as propofol, ketamine, midazolam, dexmedetomidine, and fentanyl.
• Describe risk factors and mitigation strategies, dependent on type of surgery and patient population, for surgical site infection (SSI) prevention, including skin/hair preparation and bacterial surveillance screening.
• List venous thromboembolism (VTE) risk factors and prevention measures.
• Review how use of physical and occupational therapy to promote early mobilization post-procedure may reduce incidence of pressure ulcers and length of stay.
• Explain key principles of early multimodal pain management, including key neurological pathways, early treatment of pain, and patient variability in pain thresholds.
• Compare and contrast indications for and side effects of commonly used peri-procedural analgesia agents, including acetaminophen, nonsteroidal anti-inflammatory drugs, opioids, gamma-aminobutyric acid (GABA) agents, and anxiolytics.
• Describe nonpharmacologic approaches to pain reduction, including age-appropriate distraction, massage, and the use of child life specialists when available.
• Describe adjuvant approaches to decrease opioid use in the inpatient setting and at discharge, including limiting quantity of opioids prescribed.
• Discuss patient risk factors for pain that may be difficult to control, such as history of substance abuse and others.
• Review indications, dosing parameters, and safety concerns for epidural and intravenous patient-controlled analgesia (PCA), including recommendations for basal and bolus rates, according to local context.
• Describe the different types, indications for use, natural course, and removal of temporary surgical tubes and drains, such as chest tubes, Penrose drains, closed suction drains (Jackson-Pratt, Blake, Hemovac), and others.
• Explain the basic function of the three-chamber collecting system used for chest tubes.
• Compare and contrast a suction chamber device with wall suction with a device on water seal.
• Discuss common techniques for wound care treatment, including different types of topical dressings and indications for negative pressure wound therapy.
• Describe the overall natural history of wound healing and strategies to hasten wound healing, including optimal nutrition, vitamin supplementation, and positioning.
• Review the consequences of post-procedural cytokine release, attending to potential impact on body temperature and blood inflammatory markers.
• Describe indications, contraindications, and complications for incision and drainage of cutaneous abscesses.
• Discuss appropriate empiric antibiotics for abscess management based on the local antibiogram and patient-specific factors.
• Explain the importance of antibiotic stewardship in selection of peri-procedural antibiotics.

Pediatric hospitalists should be able to:

• Demonstrate proficiency in interpreting an anesthesiology record to identify intraoperative receipt of analgesia, fluids, and blood products.
• Identify post-extubation airway issues, including stridor, and provide management as necessary.
• Demonstrate effective management of peri-procedural fluids, antibiotics, and pediatric medication dosing.
• Develop a management plan for post-anesthesia nausea and vomiting.
• Identify and treat post-procedural aspiration pneumonitis when clinically evident.
• Assess signs and symptoms to appropriately advance post-procedure diet.
• Identify abnormal progression of feeding advancement and investigate and treat causes, including prolonged ileus, obstruction, and constipation.
• Assess pain using validated, age-appropriate, and developmentally appropriate pain scales, including adaptive scales for nonverbal patients.
• Apply risk criteria for initiation of mechanical and pharmacologic VTE prophylaxis in collaboration with hematologic, surgical, and nursing colleagues.
• Direct a cost-effective and evidence-based evaluation of post-procedural fever.
• Identify signs of inappropriate positioning or complications of surgical tubes and drains and provide initial management in collaboration with the procedural team.
• Utilize optimal technique in assisting with chest tube removal, in collaboration with the procedural team per local context.
• Identify possible complications of chest tube removal and provide management, in collaboration with the procedural team per local context.
• Evaluate and accurately describe surgical wounds, pressure ulcers, and burns, including location, stage or tissue depth, and presence of exudate, necrotic tissue, or granulation tissue.
• Interpret common signs of surgical wound complications, such as infection and wound dehiscence.
• Assess fresh ostomy and fistula sites for integrity and identify concerning features that trigger timely surgical consultation.
• Diagnose superficial (early) post-procedural infection during index hospitalization, as well as deep (late) post-procedural infection for patients admitted with fever.
• Demonstrate proficiency in conducting a physical examination of skin and soft tissue infections to determine presence of cutaneous abscess and need for incision and drainage.
• Demonstrate proficiency in incision and drainage of simple cutaneous abscesses, including pre-procedural patient counseling, obtaining informed consent, and administering patient-appropriate analgesia, anxiolysis, and sedation.
• Engage surgical consultants efficiently when indicated, such as for assessment of complex abscesses, abscesses in high-risk locations, and others.
• Provide post-procedural management following abscess incision and drainage, including management of packing or surgical drains, wound care, and anticipatory guidance.

Pediatric hospitalists should be able to:

• Recognize the importance of collaborating with patients, the family/caregivers, hospital staff, anesthesiologists, other subspecialists, and primary care providers, to ensure coordinated hospital care for children during the peri-procedural period.
• Role model effective communication with patients and the family/caregivers using developmentally appropriate and family-centered language to ensure understanding and encourage participation in decision-making.
• Appreciate the importance of collaboration with nursing, child life, pain team, and/or psychology/psychiatry colleagues, to minimize patient anxiety and peri-procedural pain.
• Exemplify collaborative practice with wound care teams and available local resources, such as nursing, surgical subspecialists, dermatology, and burn units, to ensure optimal wound care during the hospitalization and a comprehensive wound care plan at time of discharge.

In order to improve efficiency and quality within their organizations, pediatric hospitalists should:

• Lead, coordinate, or participate in the development and implementation of safe, cost-effective, evidence-based care pathways to standardize peri-procedural management.
• Lead, coordinate, or participate in development of standardized handoff systems for optimal transition of care between anesthesia, surgery, and pediatric hospital medicine.
• Work with hospital staff and surgical subspecialists to coordinate ongoing educational opportunities to improve the skill set of healthcare providers in peri-procedural care.

Introduction

The American Academy of Pediatrics (AAP) and the American Heart Association (AHA), in conjunction with International Liaison Committee on Resuscitation (ILCOR), developed the Pediatric Advanced Life Support (PALS) curriculum. The PALS curriculum teaches healthcare providers to more effectively recognize potential respiratory failure and shock in infants and children and to respond with early appropriate interventions to prevent cardiopulmonary arrest. The curriculum utilizes a 4-tiered Pediatric Assessment scheme, involving a recurring cycle of “assess-categorize-decide-act,” focused on simplicity and graduated to provoke timely and appropriate early interventions. This scheme funnels emergency decision-making into respiratory (distress or failure) and circulatory (compensated or hypotensive) categories, which can be further defined based upon additional information gathered in the assessment process. The PALS curriculum further emphasizes the importance of the Resuscitation Team Concept, which encourages clear, collaborative communication. Pediatric hospitalists frequently encounter clinical situations that require immediate or emergent intervention and should be prepared to provide care within the context of PALS guidelines.

Pediatric hospitalists should be able to:

• List the common etiologies and describe early signs of respiratory failure and all forms of shock, attending to variations in presentation due to patient age.
• Explain how respiratory failure and shock can lead to cardiopulmonary arrest when early signs of distress are not recognized or acted upon.
• Describe how basic airway, breathing, circulation, disability, and exposure (ABCDE) life support maneuvers differ with age from newborns to infants and older children.
• Summarize the modalities commonly available to support the airway, breathing, and circulation in children with worsening respiratory distress, in increasing intensity/invasiveness.
• Compare and contrast the advantages and disadvantages of bag mask ventilation versus advanced airway management and describe proper selection of equipment and technique based on patient scenario.
• Differentiate the pathophysiology of hypovolemic, distributive, cardiogenic, and obstructive shock.
• Propose an approach toward management and stabilization of hypovolemic, distributive, cardiogenic, and obstructive shock, attending to differences by age.
• List common pediatric cardiac dysrhythmias and describe the most appropriate algorithm to apply for each.
• Describe the appropriate context and use of automated external defibrillators in children.
• Discuss the basic pharmacology of drugs most commonly utilized in PALS.
• Explain how assessment tools and interventions should be customized for special resuscitation situations, such as trauma, toxicological emergencies, rapid sequence intubation, procedural sedation, children with special health care needs, and others.
• Review the management of post resuscitation care and transport.
• Discuss the utility of early warning systems/pediatric rapid assessment tools designed to anticipate significant clinical instability, attending to the local context.
• Define the roles, team composition, and responsibilities of rapid response and code teams, attending to the local context.

Pediatric hospitalists should be able to:

• Complete the Pediatric Advanced Life Support course and maintain certification.
• Identify patients requiring institution of PALS techniques, accurately perform rapid assessment, and apply appropriate interventions.
• Identify early warning signs of acute respiratory distress and cardiac compromise and institute corrective actions to avert further deterioration.
• Perform effective basic life support and cardiopulmonary resuscitation skills, using appropriate weight/size-based resuscitation tools.
• Stabilize the airway, using noninvasive techniques (including bag-mask ventilation and oral airway insertion) and invasive airway management techniques in collaboration with other services, according to local context.
• Formulate a differential for tension pneumothorax and perform decompressive needle thoracostomy.
• Identify and treat common pediatric cardiac dysrhythmias.
• Utilize an Automated External Defibrillator under appropriate circumstances.
• Obtain peripheral or central vascular access by placement of intravenous, intraosseous, or central venous catheters in collaboration with other services, according to local context.
• Apply PALS principles to special resuscitations, such as toxicological emergencies, procedural sedation, or trauma.
• Lead or participate as a member of a rapid response and/or resuscitation team, arranging for transfer to a higher level of care or transport to another facility as appropriate.
• Manage a clinical team debrief immediately following a resuscitation.

Pediatric hospitalists should be able to:

• Advocate for presence of the family/caregivers during resuscitation when appropriate.
• Realize the importance of effective and compassionate communication with the family/caregivers.
• Acknowledge the value of collaboration with social work, chaplain, the primary care provider, and others to enhance support for the family/caregivers.
• Appreciate the importance of situation monitoring, leadership, direct and closed-loop communication, and mutual support in effective team functioning during resuscitation events.

In order to improve efficiency and quality within their organizations, pediatric hospitalists should:

• Lead, coordinate, or participate in the development and implementation of a local Pediatric Advanced Life Support training program.
• Lead, coordinate, or participate in the development and implementation of pediatric mock code training at their local institution.
• Collaborate with hospital administration to ensure code carts are pediatric-specific and contain adequate, appropriate equipment.
• Collaborate with hospital administration to create inter-facility transport and affiliation agreements between community hospitals and pediatric tertiary care centers to foster effective and appropriate triage of sick and injured children.
• Advocate for a statewide Emergency Medical Systems (EMS) for Children program which places pediatric emergency care in its proper place within the EMS system.

Introduction

The American Academy of Pediatrics (AAP) and the American Heart Association (AHA), in conjunction with International Liaison Committee on Resuscitation (ILCOR), developed the Pediatric Advanced Life Support (PALS) curriculum. The PALS curriculum teaches healthcare providers to more effectively recognize potential respiratory failure and shock in infants and children and to respond with early appropriate interventions to prevent cardiopulmonary arrest. The curriculum utilizes a 4-tiered Pediatric Assessment scheme, involving a recurring cycle of “assess-categorize-decide-act,” focused on simplicity and graduated to provoke timely and appropriate early interventions. This scheme funnels emergency decision-making into respiratory (distress or failure) and circulatory (compensated or hypotensive) categories, which can be further defined based upon additional information gathered in the assessment process. The PALS curriculum further emphasizes the importance of the Resuscitation Team Concept, which encourages clear, collaborative communication. Pediatric hospitalists frequently encounter clinical situations that require immediate or emergent intervention and should be prepared to provide care within the context of PALS guidelines.

Pediatric hospitalists should be able to:

• List the common etiologies and describe early signs of respiratory failure and all forms of shock, attending to variations in presentation due to patient age.
• Explain how respiratory failure and shock can lead to cardiopulmonary arrest when early signs of distress are not recognized or acted upon.
• Describe how basic airway, breathing, circulation, disability, and exposure (ABCDE) life support maneuvers differ with age from newborns to infants and older children.
• Summarize the modalities commonly available to support the airway, breathing, and circulation in children with worsening respiratory distress, in increasing intensity/invasiveness.
• Compare and contrast the advantages and disadvantages of bag mask ventilation versus advanced airway management and describe proper selection of equipment and technique based on patient scenario.
• Differentiate the pathophysiology of hypovolemic, distributive, cardiogenic, and obstructive shock.
• Propose an approach toward management and stabilization of hypovolemic, distributive, cardiogenic, and obstructive shock, attending to differences by age.
• List common pediatric cardiac dysrhythmias and describe the most appropriate algorithm to apply for each.
• Describe the appropriate context and use of automated external defibrillators in children.
• Discuss the basic pharmacology of drugs most commonly utilized in PALS.
• Explain how assessment tools and interventions should be customized for special resuscitation situations, such as trauma, toxicological emergencies, rapid sequence intubation, procedural sedation, children with special health care needs, and others.
• Review the management of post resuscitation care and transport.
• Discuss the utility of early warning systems/pediatric rapid assessment tools designed to anticipate significant clinical instability, attending to the local context.
• Define the roles, team composition, and responsibilities of rapid response and code teams, attending to the local context.

Pediatric hospitalists should be able to:

• Complete the Pediatric Advanced Life Support course and maintain certification.
• Identify patients requiring institution of PALS techniques, accurately perform rapid assessment, and apply appropriate interventions.
• Identify early warning signs of acute respiratory distress and cardiac compromise and institute corrective actions to avert further deterioration.
• Perform effective basic life support and cardiopulmonary resuscitation skills, using appropriate weight/size-based resuscitation tools.
• Stabilize the airway, using noninvasive techniques (including bag-mask ventilation and oral airway insertion) and invasive airway management techniques in collaboration with other services, according to local context.
• Formulate a differential for tension pneumothorax and perform decompressive needle thoracostomy.
• Identify and treat common pediatric cardiac dysrhythmias.
• Utilize an Automated External Defibrillator under appropriate circumstances.
• Obtain peripheral or central vascular access by placement of intravenous, intraosseous, or central venous catheters in collaboration with other services, according to local context.
• Apply PALS principles to special resuscitations, such as toxicological emergencies, procedural sedation, or trauma.
• Lead or participate as a member of a rapid response and/or resuscitation team, arranging for transfer to a higher level of care or transport to another facility as appropriate.
• Manage a clinical team debrief immediately following a resuscitation.

Pediatric hospitalists should be able to:

• Advocate for presence of the family/caregivers during resuscitation when appropriate.
• Realize the importance of effective and compassionate communication with the family/caregivers.
• Acknowledge the value of collaboration with social work, chaplain, the primary care provider, and others to enhance support for the family/caregivers.
• Appreciate the importance of situation monitoring, leadership, direct and closed-loop communication, and mutual support in effective team functioning during resuscitation events.

In order to improve efficiency and quality within their organizations, pediatric hospitalists should:

• Lead, coordinate, or participate in the development and implementation of a local Pediatric Advanced Life Support training program.
• Lead, coordinate, or participate in the development and implementation of pediatric mock code training at their local institution.
• Collaborate with hospital administration to ensure code carts are pediatric-specific and contain adequate, appropriate equipment.
• Collaborate with hospital administration to create inter-facility transport and affiliation agreements between community hospitals and pediatric tertiary care centers to foster effective and appropriate triage of sick and injured children.
• Advocate for a statewide Emergency Medical Systems (EMS) for Children program which places pediatric emergency care in its proper place within the EMS system.

Introduction

The American Academy of Pediatrics (AAP) and the American Heart Association (AHA), in conjunction with International Liaison Committee on Resuscitation (ILCOR), developed the Pediatric Advanced Life Support (PALS) curriculum. The PALS curriculum teaches healthcare providers to more effectively recognize potential respiratory failure and shock in infants and children and to respond with early appropriate interventions to prevent cardiopulmonary arrest. The curriculum utilizes a 4-tiered Pediatric Assessment scheme, involving a recurring cycle of “assess-categorize-decide-act,” focused on simplicity and graduated to provoke timely and appropriate early interventions. This scheme funnels emergency decision-making into respiratory (distress or failure) and circulatory (compensated or hypotensive) categories, which can be further defined based upon additional information gathered in the assessment process. The PALS curriculum further emphasizes the importance of the Resuscitation Team Concept, which encourages clear, collaborative communication. Pediatric hospitalists frequently encounter clinical situations that require immediate or emergent intervention and should be prepared to provide care within the context of PALS guidelines.

Pediatric hospitalists should be able to:

• List the common etiologies and describe early signs of respiratory failure and all forms of shock, attending to variations in presentation due to patient age.
• Explain how respiratory failure and shock can lead to cardiopulmonary arrest when early signs of distress are not recognized or acted upon.
• Describe how basic airway, breathing, circulation, disability, and exposure (ABCDE) life support maneuvers differ with age from newborns to infants and older children.
• Summarize the modalities commonly available to support the airway, breathing, and circulation in children with worsening respiratory distress, in increasing intensity/invasiveness.
• Compare and contrast the advantages and disadvantages of bag mask ventilation versus advanced airway management and describe proper selection of equipment and technique based on patient scenario.
• Differentiate the pathophysiology of hypovolemic, distributive, cardiogenic, and obstructive shock.
• Propose an approach toward management and stabilization of hypovolemic, distributive, cardiogenic, and obstructive shock, attending to differences by age.
• List common pediatric cardiac dysrhythmias and describe the most appropriate algorithm to apply for each.
• Describe the appropriate context and use of automated external defibrillators in children.
• Discuss the basic pharmacology of drugs most commonly utilized in PALS.
• Explain how assessment tools and interventions should be customized for special resuscitation situations, such as trauma, toxicological emergencies, rapid sequence intubation, procedural sedation, children with special health care needs, and others.
• Review the management of post resuscitation care and transport.
• Discuss the utility of early warning systems/pediatric rapid assessment tools designed to anticipate significant clinical instability, attending to the local context.
• Define the roles, team composition, and responsibilities of rapid response and code teams, attending to the local context.

Pediatric hospitalists should be able to:

• Complete the Pediatric Advanced Life Support course and maintain certification.
• Identify patients requiring institution of PALS techniques, accurately perform rapid assessment, and apply appropriate interventions.
• Identify early warning signs of acute respiratory distress and cardiac compromise and institute corrective actions to avert further deterioration.
• Perform effective basic life support and cardiopulmonary resuscitation skills, using appropriate weight/size-based resuscitation tools.
• Stabilize the airway, using noninvasive techniques (including bag-mask ventilation and oral airway insertion) and invasive airway management techniques in collaboration with other services, according to local context.
• Formulate a differential for tension pneumothorax and perform decompressive needle thoracostomy.
• Identify and treat common pediatric cardiac dysrhythmias.
• Utilize an Automated External Defibrillator under appropriate circumstances.
• Obtain peripheral or central vascular access by placement of intravenous, intraosseous, or central venous catheters in collaboration with other services, according to local context.
• Apply PALS principles to special resuscitations, such as toxicological emergencies, procedural sedation, or trauma.
• Lead or participate as a member of a rapid response and/or resuscitation team, arranging for transfer to a higher level of care or transport to another facility as appropriate.
• Manage a clinical team debrief immediately following a resuscitation.

Pediatric hospitalists should be able to:

• Advocate for presence of the family/caregivers during resuscitation when appropriate.
• Realize the importance of effective and compassionate communication with the family/caregivers.
• Acknowledge the value of collaboration with social work, chaplain, the primary care provider, and others to enhance support for the family/caregivers.
• Appreciate the importance of situation monitoring, leadership, direct and closed-loop communication, and mutual support in effective team functioning during resuscitation events.

In order to improve efficiency and quality within their organizations, pediatric hospitalists should:

• Lead, coordinate, or participate in the development and implementation of a local Pediatric Advanced Life Support training program.
• Lead, coordinate, or participate in the development and implementation of pediatric mock code training at their local institution.
• Collaborate with hospital administration to ensure code carts are pediatric-specific and contain adequate, appropriate equipment.
• Collaborate with hospital administration to create inter-facility transport and affiliation agreements between community hospitals and pediatric tertiary care centers to foster effective and appropriate triage of sick and injured children.
• Advocate for a statewide Emergency Medical Systems (EMS) for Children program which places pediatric emergency care in its proper place within the EMS system.

Introduction

Acute, chronic, and procedural pain are common conditions in the pediatric inpatient setting. They are most often associated with new-onset illness or infection, trauma, burns, post-surgical sequelae, or exacerbation of chronic disease. Chronic pain complicates effective control of acute pain and may be associated with central sensitization and neuropsychological changes that impact pain perception. Despite advances in understanding of the pathophysiology and management of pain in children, barriers to effective pain management still exist, such as fear of harmful side effects, difficulty in pain assessment in young and/or developmentally delayed pediatric patients, healthcare provider bias, and concerns of addiction and diversion of controlled medications. Pediatric hospitalists should enhance pain management services through the direct provision of effective care and lead development of a systematic approach to pain management in institutions and communities.

Pediatric hospitalists should be able to:

• Describe the pathophysiology and developmental aspects of pain in infants, children, and adolescents.
• Explain how pain, anxiety, and fear interrelate and discuss strategies for addressing each.
• Understand central sensitization and its role in the development of chronic pain.
• Identify psychologic components that contribute to maintenance of chronic pain, including parental anxiety and catastrophizing.
• List the indications and contraindications for the main classes of drugs used for pain management, including nonsteroidal anti-inflammatory drugs, opioids, and topical and local anesthetics.
• Discuss the pharmacology of medications commonly used for analgesia, including route of administration, dosing range, and expected side effects.
• Discuss the pharmacology of medications used for anxiolysis, including route of administration, dosing range, and expected side effects.
• Describe the effect of age (including neonate, young child, and adolescent) on analgesia and on the pharmacology of medications used for analgesia and anxiolysis.
• Describe how diseases, such as obstructive sleep apnea, liver or kidney disease, and others, affect pharmacology of analgesic medications.
• Compare and contrast the risks and benefits of various modalities of drug delivery, attending to drug delivery, side effects, and invasiveness.
• Review the current state of the opioid crisis as it relates to pediatrics, including risks of opioid misuse, opioid abuse, opioid addiction, overdose, and opioid diversion in teens.
• Describe neonatal abstinence syndrome, including the current increased prevalence of this syndrome in infants.
• Describe risk factors for opioid misuse and abuse in the adolescent population.
• List appropriate monitoring techniques for patients receiving analgesics, anxiolytics, and other associated medications.
• List the appropriate monitoring requirements for patient-controlled analgesia (PCA) and nurse-controlled analgesia (NCA) delivery methods.
• Describe the pharmacology of and the indications for reversal agents for specific classes of drugs used for pain management.
• Describe the role of the pediatric pain consultant/pain management team and discuss barriers to local availability.
• Discuss how use of adjuvant medications, such as antidepressants, anticonvulsants, anxiolytics, and sleep medications, can be used most appropriately for pain management.
• Summarize common potential side effects and harms associated with pain treatments, attending to effects on the respiratory, renal, gastrointestinal, and neurologic systems.
• Discuss how complementary techniques, such as behavioral therapy, play therapy, physical therapy, bundling, glucose water pacifiers, presence of the family/caregivers, visual imagery, deep breathing, music, and others can be utilized to manage pain and anxiety.
• Describe nonpharmacologic, alternative therapies used for certain types of chronic pain as adjuncts to traditional therapies, such as acupuncture, massage therapy, hypnosis, and others.

Pediatric hospitalists should be able to:

• Assess the presence and level of pain in children regardless of developmental level, utilizing history, physical examination, physiologic parameters, and validated pediatric pain scales.
• Create a pain management plan individualized to the patient that utilizes a tiered approach with nonpharmacologic treatments (such as distraction, comfort measures, and others) and both nonnarcotic and narcotic medications.
• Create a pain plan for patients undergoing procedures not requiring anesthesia/deep sedation (such as intravenous line placement, wound debridement, dressing changes, and others).
• Prescribe doses of analgesic medication that improve pain while minimizing side effects.
• Demonstrate proficiency in managing breakthrough pain utilizing both opioid and nonopioid pain medications
• Demonstrate competence in correctly ordering dosing of pain medications when changing from one route of delivery to another, or when switching from one pain medication type to another.
• Select and order pain and anxiety medications in safe and cost-effective manner.
• Create weaning strategies for pain and anxiolytic medication regimens that reduce the risk for withdrawal symptoms.
• Perform careful reassessments daily and as needed, note changes in clinical status, pain, side effects, tolerance, and withdrawal, and respond with appropriate actions.
• Order appropriate blood testing and equipment monitoring in accordance with individualized needs and correctly interpret the data.
• Anticipate and identify potential side effects of analgesic and anxiolytic medications, including opioid hyperalgesia and nonsteroidal medication induced renal or gastrointestinal injury, and respond with appropriate actions.
• Identify patients at risk for development of chronic pain and involve appropriate consultants to assist with long-term management.
• Identify patients with neuropathic pain and develop a treatment plan with assistance from appropriate consultants.
• Identify discharge needs and create a comprehensive discharge plan, including appropriate medical equipment, required prescriptions and plan for refills, and follow-up appointments for specialty services.
• Effectively communicate with patients and the family/caregivers about risks and benefits of using opioid and nonopioid medications after discharge, including the need for proper storage and disposal of controlled pain medications.

Pediatric hospitalists should be able to:

• Realize the importance of educating patients and the family/caregivers on various aspects of pain, including etiologies, management, and impact on the healing process.
• Appreciate the importance of involving the primary care provider in the therapeutic process early in the hospitalization.
• Recognize the impact that uncontrolled pain has on the emotional and physical well-being of patients and the family/caregivers.
• Reflect on the impact that race, ethnicity, and culture may have on pain management, medication responses, and side effects, including the occurrence of health disparities related to adequate pain control.
• Acknowledge the value of collaboration with subspecialists and the primary care provider to ensure coordinated longitudinal care for children receiving chronic pain management services.

In order to improve efficiency and quality within their organizations, pediatric hospitalists should:

• Work with hospital administration, hospital staff, subspecialists, and others to implement a comprehensive, systematic approach to pain management across the continuum of care.
• Lead, coordinate, or participate in the development and implementation of cost-effective, safe, evidence-based care to standardize the evaluation and management for hospitalized children with pain, including standardization of pain protocols in the electronic medical record when available.
• Lead, coordinate, or participate in education of healthcare providers who work with children about pediatric pain assessment and safe medication use.
• Work in consultation with surgical staff to prioritize and improve the management of pain in pediatric surgical patients.
• Collaborate with hospital administration and others on efforts to mitigate patient opioid misuse and diversion risks within the hospital organization by advocating for opioid education among healthcare providers.
• Work with hospital informaticists to implement clear and safe ordering of pain medications and efficient access to data on pain medication usage and prescribing.

Introduction

Acute, chronic, and procedural pain are common conditions in the pediatric inpatient setting. They are most often associated with new-onset illness or infection, trauma, burns, post-surgical sequelae, or exacerbation of chronic disease. Chronic pain complicates effective control of acute pain and may be associated with central sensitization and neuropsychological changes that impact pain perception. Despite advances in understanding of the pathophysiology and management of pain in children, barriers to effective pain management still exist, such as fear of harmful side effects, difficulty in pain assessment in young and/or developmentally delayed pediatric patients, healthcare provider bias, and concerns of addiction and diversion of controlled medications. Pediatric hospitalists should enhance pain management services through the direct provision of effective care and lead development of a systematic approach to pain management in institutions and communities.

Pediatric hospitalists should be able to:

• Describe the pathophysiology and developmental aspects of pain in infants, children, and adolescents.
• Explain how pain, anxiety, and fear interrelate and discuss strategies for addressing each.
• Understand central sensitization and its role in the development of chronic pain.
• Identify psychologic components that contribute to maintenance of chronic pain, including parental anxiety and catastrophizing.
• List the indications and contraindications for the main classes of drugs used for pain management, including nonsteroidal anti-inflammatory drugs, opioids, and topical and local anesthetics.
• Discuss the pharmacology of medications commonly used for analgesia, including route of administration, dosing range, and expected side effects.
• Discuss the pharmacology of medications used for anxiolysis, including route of administration, dosing range, and expected side effects.
• Describe the effect of age (including neonate, young child, and adolescent) on analgesia and on the pharmacology of medications used for analgesia and anxiolysis.
• Describe how diseases, such as obstructive sleep apnea, liver or kidney disease, and others, affect pharmacology of analgesic medications.
• Compare and contrast the risks and benefits of various modalities of drug delivery, attending to drug delivery, side effects, and invasiveness.
• Review the current state of the opioid crisis as it relates to pediatrics, including risks of opioid misuse, opioid abuse, opioid addiction, overdose, and opioid diversion in teens.
• Describe neonatal abstinence syndrome, including the current increased prevalence of this syndrome in infants.
• Describe risk factors for opioid misuse and abuse in the adolescent population.
• List appropriate monitoring techniques for patients receiving analgesics, anxiolytics, and other associated medications.
• List the appropriate monitoring requirements for patient-controlled analgesia (PCA) and nurse-controlled analgesia (NCA) delivery methods.
• Describe the pharmacology of and the indications for reversal agents for specific classes of drugs used for pain management.
• Describe the role of the pediatric pain consultant/pain management team and discuss barriers to local availability.
• Discuss how use of adjuvant medications, such as antidepressants, anticonvulsants, anxiolytics, and sleep medications, can be used most appropriately for pain management.
• Summarize common potential side effects and harms associated with pain treatments, attending to effects on the respiratory, renal, gastrointestinal, and neurologic systems.
• Discuss how complementary techniques, such as behavioral therapy, play therapy, physical therapy, bundling, glucose water pacifiers, presence of the family/caregivers, visual imagery, deep breathing, music, and others can be utilized to manage pain and anxiety.
• Describe nonpharmacologic, alternative therapies used for certain types of chronic pain as adjuncts to traditional therapies, such as acupuncture, massage therapy, hypnosis, and others.

Pediatric hospitalists should be able to:

• Assess the presence and level of pain in children regardless of developmental level, utilizing history, physical examination, physiologic parameters, and validated pediatric pain scales.
• Create a pain management plan individualized to the patient that utilizes a tiered approach with nonpharmacologic treatments (such as distraction, comfort measures, and others) and both nonnarcotic and narcotic medications.
• Create a pain plan for patients undergoing procedures not requiring anesthesia/deep sedation (such as intravenous line placement, wound debridement, dressing changes, and others).
• Prescribe doses of analgesic medication that improve pain while minimizing side effects.
• Demonstrate proficiency in managing breakthrough pain utilizing both opioid and nonopioid pain medications
• Demonstrate competence in correctly ordering dosing of pain medications when changing from one route of delivery to another, or when switching from one pain medication type to another.
• Select and order pain and anxiety medications in safe and cost-effective manner.
• Create weaning strategies for pain and anxiolytic medication regimens that reduce the risk for withdrawal symptoms.
• Perform careful reassessments daily and as needed, note changes in clinical status, pain, side effects, tolerance, and withdrawal, and respond with appropriate actions.
• Order appropriate blood testing and equipment monitoring in accordance with individualized needs and correctly interpret the data.
• Anticipate and identify potential side effects of analgesic and anxiolytic medications, including opioid hyperalgesia and nonsteroidal medication induced renal or gastrointestinal injury, and respond with appropriate actions.
• Identify patients at risk for development of chronic pain and involve appropriate consultants to assist with long-term management.
• Identify patients with neuropathic pain and develop a treatment plan with assistance from appropriate consultants.
• Identify discharge needs and create a comprehensive discharge plan, including appropriate medical equipment, required prescriptions and plan for refills, and follow-up appointments for specialty services.
• Effectively communicate with patients and the family/caregivers about risks and benefits of using opioid and nonopioid medications after discharge, including the need for proper storage and disposal of controlled pain medications.

Pediatric hospitalists should be able to:

• Realize the importance of educating patients and the family/caregivers on various aspects of pain, including etiologies, management, and impact on the healing process.
• Appreciate the importance of involving the primary care provider in the therapeutic process early in the hospitalization.
• Recognize the impact that uncontrolled pain has on the emotional and physical well-being of patients and the family/caregivers.
• Reflect on the impact that race, ethnicity, and culture may have on pain management, medication responses, and side effects, including the occurrence of health disparities related to adequate pain control.
• Acknowledge the value of collaboration with subspecialists and the primary care provider to ensure coordinated longitudinal care for children receiving chronic pain management services.

In order to improve efficiency and quality within their organizations, pediatric hospitalists should:

• Work with hospital administration, hospital staff, subspecialists, and others to implement a comprehensive, systematic approach to pain management across the continuum of care.
• Lead, coordinate, or participate in the development and implementation of cost-effective, safe, evidence-based care to standardize the evaluation and management for hospitalized children with pain, including standardization of pain protocols in the electronic medical record when available.
• Lead, coordinate, or participate in education of healthcare providers who work with children about pediatric pain assessment and safe medication use.
• Work in consultation with surgical staff to prioritize and improve the management of pain in pediatric surgical patients.
• Collaborate with hospital administration and others on efforts to mitigate patient opioid misuse and diversion risks within the hospital organization by advocating for opioid education among healthcare providers.
• Work with hospital informaticists to implement clear and safe ordering of pain medications and efficient access to data on pain medication usage and prescribing.

Introduction

Acute, chronic, and procedural pain are common conditions in the pediatric inpatient setting. They are most often associated with new-onset illness or infection, trauma, burns, post-surgical sequelae, or exacerbation of chronic disease. Chronic pain complicates effective control of acute pain and may be associated with central sensitization and neuropsychological changes that impact pain perception. Despite advances in understanding of the pathophysiology and management of pain in children, barriers to effective pain management still exist, such as fear of harmful side effects, difficulty in pain assessment in young and/or developmentally delayed pediatric patients, healthcare provider bias, and concerns of addiction and diversion of controlled medications. Pediatric hospitalists should enhance pain management services through the direct provision of effective care and lead development of a systematic approach to pain management in institutions and communities.

Pediatric hospitalists should be able to:

• Describe the pathophysiology and developmental aspects of pain in infants, children, and adolescents.
• Explain how pain, anxiety, and fear interrelate and discuss strategies for addressing each.
• Understand central sensitization and its role in the development of chronic pain.
• Identify psychologic components that contribute to maintenance of chronic pain, including parental anxiety and catastrophizing.
• List the indications and contraindications for the main classes of drugs used for pain management, including nonsteroidal anti-inflammatory drugs, opioids, and topical and local anesthetics.
• Discuss the pharmacology of medications commonly used for analgesia, including route of administration, dosing range, and expected side effects.
• Discuss the pharmacology of medications used for anxiolysis, including route of administration, dosing range, and expected side effects.
• Describe the effect of age (including neonate, young child, and adolescent) on analgesia and on the pharmacology of medications used for analgesia and anxiolysis.
• Describe how diseases, such as obstructive sleep apnea, liver or kidney disease, and others, affect pharmacology of analgesic medications.
• Compare and contrast the risks and benefits of various modalities of drug delivery, attending to drug delivery, side effects, and invasiveness.
• Review the current state of the opioid crisis as it relates to pediatrics, including risks of opioid misuse, opioid abuse, opioid addiction, overdose, and opioid diversion in teens.
• Describe neonatal abstinence syndrome, including the current increased prevalence of this syndrome in infants.
• Describe risk factors for opioid misuse and abuse in the adolescent population.
• List appropriate monitoring techniques for patients receiving analgesics, anxiolytics, and other associated medications.
• List the appropriate monitoring requirements for patient-controlled analgesia (PCA) and nurse-controlled analgesia (NCA) delivery methods.
• Describe the pharmacology of and the indications for reversal agents for specific classes of drugs used for pain management.
• Describe the role of the pediatric pain consultant/pain management team and discuss barriers to local availability.
• Discuss how use of adjuvant medications, such as antidepressants, anticonvulsants, anxiolytics, and sleep medications, can be used most appropriately for pain management.
• Summarize common potential side effects and harms associated with pain treatments, attending to effects on the respiratory, renal, gastrointestinal, and neurologic systems.
• Discuss how complementary techniques, such as behavioral therapy, play therapy, physical therapy, bundling, glucose water pacifiers, presence of the family/caregivers, visual imagery, deep breathing, music, and others can be utilized to manage pain and anxiety.
• Describe nonpharmacologic, alternative therapies used for certain types of chronic pain as adjuncts to traditional therapies, such as acupuncture, massage therapy, hypnosis, and others.

Pediatric hospitalists should be able to:

• Assess the presence and level of pain in children regardless of developmental level, utilizing history, physical examination, physiologic parameters, and validated pediatric pain scales.
• Create a pain management plan individualized to the patient that utilizes a tiered approach with nonpharmacologic treatments (such as distraction, comfort measures, and others) and both nonnarcotic and narcotic medications.
• Create a pain plan for patients undergoing procedures not requiring anesthesia/deep sedation (such as intravenous line placement, wound debridement, dressing changes, and others).
• Prescribe doses of analgesic medication that improve pain while minimizing side effects.
• Demonstrate proficiency in managing breakthrough pain utilizing both opioid and nonopioid pain medications
• Demonstrate competence in correctly ordering dosing of pain medications when changing from one route of delivery to another, or when switching from one pain medication type to another.
• Select and order pain and anxiety medications in safe and cost-effective manner.
• Create weaning strategies for pain and anxiolytic medication regimens that reduce the risk for withdrawal symptoms.
• Perform careful reassessments daily and as needed, note changes in clinical status, pain, side effects, tolerance, and withdrawal, and respond with appropriate actions.
• Order appropriate blood testing and equipment monitoring in accordance with individualized needs and correctly interpret the data.
• Anticipate and identify potential side effects of analgesic and anxiolytic medications, including opioid hyperalgesia and nonsteroidal medication induced renal or gastrointestinal injury, and respond with appropriate actions.
• Identify patients at risk for development of chronic pain and involve appropriate consultants to assist with long-term management.
• Identify patients with neuropathic pain and develop a treatment plan with assistance from appropriate consultants.
• Identify discharge needs and create a comprehensive discharge plan, including appropriate medical equipment, required prescriptions and plan for refills, and follow-up appointments for specialty services.
• Effectively communicate with patients and the family/caregivers about risks and benefits of using opioid and nonopioid medications after discharge, including the need for proper storage and disposal of controlled pain medications.

Pediatric hospitalists should be able to:

• Realize the importance of educating patients and the family/caregivers on various aspects of pain, including etiologies, management, and impact on the healing process.
• Appreciate the importance of involving the primary care provider in the therapeutic process early in the hospitalization.
• Recognize the impact that uncontrolled pain has on the emotional and physical well-being of patients and the family/caregivers.
• Reflect on the impact that race, ethnicity, and culture may have on pain management, medication responses, and side effects, including the occurrence of health disparities related to adequate pain control.
• Acknowledge the value of collaboration with subspecialists and the primary care provider to ensure coordinated longitudinal care for children receiving chronic pain management services.

In order to improve efficiency and quality within their organizations, pediatric hospitalists should:

• Work with hospital administration, hospital staff, subspecialists, and others to implement a comprehensive, systematic approach to pain management across the continuum of care.
• Lead, coordinate, or participate in the development and implementation of cost-effective, safe, evidence-based care to standardize the evaluation and management for hospitalized children with pain, including standardization of pain protocols in the electronic medical record when available.
• Lead, coordinate, or participate in education of healthcare providers who work with children about pediatric pain assessment and safe medication use.
• Work in consultation with surgical staff to prioritize and improve the management of pain in pediatric surgical patients.
• Collaborate with hospital administration and others on efforts to mitigate patient opioid misuse and diversion risks within the hospital organization by advocating for opioid education among healthcare providers.
• Work with hospital informaticists to implement clear and safe ordering of pain medications and efficient access to data on pain medication usage and prescribing.

Introduction

Respiratory distress and respiratory failure are encountered in a significant number of pediatric conditions in acute care and inpatient settings. Early identification and treatment of respiratory compromise remain critically important to the effective practice of pediatric hospital medicine. Pediatric hospitalists frequently encounter patients requiring oxygen and airway management and should be skilled in appropriate airway management and oxygen delivery in order to reduce respiratory related morbidity and mortality for hospitalized children.

Pediatric hospitalists should be able to:

• Describe the different modes of oxygen delivery, including nasal cannula, simple face mask, nonrebreather, and partial rebreather masks, and the approximate amount of oxygen delivered with each.
• Describe the indications for and uses of different types of airway equipment, including oropharyngeal, nasopharyngeal, laryngeal mask, and tracheal airways.
• Compare and contrast low flow and high flow oxygen delivery systems.
• Describe types of noninvasive ventilation such as continuous or bi-level pressure delivery systems, and discuss their indications for use, according to local practice.
• Describe the basic anatomy of the upper respiratory tract and the anatomic differences between infants, children, and adolescents.
• Discuss factors that may complicate airway management, including anatomic abnormalities of the face and oropharynx, neurologic impairment, and trauma.
• Distinguish between the use of oxygen delivery devices and airway management devices in the management of impending respiratory failure.
• Discuss the steps involved in assessing and securing a patient’s airway, including proper airway positioning, suctioning, selection and use of the appropriate airway equipment, and the use of adjunctive medications.
• List the items essential to have available at the bedside or in an emergency supply cart in the event of respiratory compromise, including suction, oxygen, oxygen delivery systems, pediatric sizes of advanced airway equipment, and resuscitation medications.
• Identify the various forms of monitoring related to assessment of oxygenation and ventilation, including cardiorespiratory monitors, pulse oximetry, capnography, and blood gas sampling.
• Summarize commonly encountered complications and hospital-acquired conditions (HACs) associated with use of oxygen delivery and airway management devices, attending to potential harms to the skin, airway, and lung.
• Describe and interpret blood gas results, including arterial, venous, and capillary.
• Identify the indications for consultation with an otorhinolaryngologist, anesthesiologist, intensivist, surgeon, or other subspecialist regarding airway management.

Pediatric hospitalists should be able to:

• Identify patients needing or at risk for needing airway management devices or oxygen delivery and initiate appropriate use.
• Order appropriate monitoring for patients receiving oxygen or using airway devices and correctly interpret monitor data.
• Correctly use standard head tilt and jaw thrust maneuvers to open a child’s airway.
• Select and use the appropriate method of oxygen delivery according to the clinical situation.
• Select the appropriate airway device and size and establish a secure airway when indicated.
• Utilize noninvasive ventilation when clinically indicated, according to local context.
• Use suction equipment to clear the airway as appropriate.
• Respond with appropriate corrective action when a tracheostomy tube becomes obstructed or dislodged in patients with mature tracts, according to local context.
• Wean oxygen proactively when the clinical situation allows.
• Implement a patient-specific plan for respiratory care in collaboration with nursing, respiratory therapy, subspecialists, and other healthcare providers.
• Implement a plan to ensure healthcare team awareness of a critical airway when present.
• Engage appropriate consultants to ensure proper airway management as appropriate.

Pediatric hospitalists should be able to:

• Exemplify responsible airway management and oxygen delivery when the clinical need arises.
• Acknowledge the importance of maintaining skills in airway management and oxygen delivery.
• Appreciate the importance of remaining current with relevant continuing education activities, including Pediatric Advanced Life Support (PALS).
• Exemplify and advocate for effective communication with the patient and the family/caregivers regarding the need for airway management, oxygen delivery, and the care plan.

In order to improve efficiency and quality within their organizations, pediatric hospitalists should:

• Collaborate with hospital administration to optimize appropriate utilization of oxygen therapies and oxygenation monitoring devices.
• Lead, coordinate, or participate in the development of hospital systems designed to detect patients with respiratory compromise early and provide an appropriate, rapid response.
• Lead, coordinate, or participate in educational opportunities and systems to improve airway skills and effective response for healthcare providers, including PALS training, the use of mock codes, and simulation training where available.
• Collaborate with subspecialists and hospital administration to establish a system of appropriate identification and response to patients with atypical anatomy and the presence of a critical airway.
• Work with hospital administration to ensure that age and size-appropriate airway and emergency equipment is available for each patient room and care area.
• Collaborate to create and sustain practices to reduce potential harms from HACs associated with use of respiratory devices.

Introduction

Respiratory distress and respiratory failure are encountered in a significant number of pediatric conditions in acute care and inpatient settings. Early identification and treatment of respiratory compromise remain critically important to the effective practice of pediatric hospital medicine. Pediatric hospitalists frequently encounter patients requiring oxygen and airway management and should be skilled in appropriate airway management and oxygen delivery in order to reduce respiratory related morbidity and mortality for hospitalized children.

Pediatric hospitalists should be able to:

• Describe the different modes of oxygen delivery, including nasal cannula, simple face mask, nonrebreather, and partial rebreather masks, and the approximate amount of oxygen delivered with each.
• Describe the indications for and uses of different types of airway equipment, including oropharyngeal, nasopharyngeal, laryngeal mask, and tracheal airways.
• Compare and contrast low flow and high flow oxygen delivery systems.
• Describe types of noninvasive ventilation such as continuous or bi-level pressure delivery systems, and discuss their indications for use, according to local practice.
• Describe the basic anatomy of the upper respiratory tract and the anatomic differences between infants, children, and adolescents.
• Discuss factors that may complicate airway management, including anatomic abnormalities of the face and oropharynx, neurologic impairment, and trauma.
• Distinguish between the use of oxygen delivery devices and airway management devices in the management of impending respiratory failure.
• Discuss the steps involved in assessing and securing a patient’s airway, including proper airway positioning, suctioning, selection and use of the appropriate airway equipment, and the use of adjunctive medications.
• List the items essential to have available at the bedside or in an emergency supply cart in the event of respiratory compromise, including suction, oxygen, oxygen delivery systems, pediatric sizes of advanced airway equipment, and resuscitation medications.
• Identify the various forms of monitoring related to assessment of oxygenation and ventilation, including cardiorespiratory monitors, pulse oximetry, capnography, and blood gas sampling.
• Summarize commonly encountered complications and hospital-acquired conditions (HACs) associated with use of oxygen delivery and airway management devices, attending to potential harms to the skin, airway, and lung.
• Describe and interpret blood gas results, including arterial, venous, and capillary.
• Identify the indications for consultation with an otorhinolaryngologist, anesthesiologist, intensivist, surgeon, or other subspecialist regarding airway management.

Pediatric hospitalists should be able to:

• Identify patients needing or at risk for needing airway management devices or oxygen delivery and initiate appropriate use.
• Order appropriate monitoring for patients receiving oxygen or using airway devices and correctly interpret monitor data.
• Correctly use standard head tilt and jaw thrust maneuvers to open a child’s airway.
• Select and use the appropriate method of oxygen delivery according to the clinical situation.
• Select the appropriate airway device and size and establish a secure airway when indicated.
• Utilize noninvasive ventilation when clinically indicated, according to local context.
• Use suction equipment to clear the airway as appropriate.
• Respond with appropriate corrective action when a tracheostomy tube becomes obstructed or dislodged in patients with mature tracts, according to local context.
• Wean oxygen proactively when the clinical situation allows.
• Implement a patient-specific plan for respiratory care in collaboration with nursing, respiratory therapy, subspecialists, and other healthcare providers.
• Implement a plan to ensure healthcare team awareness of a critical airway when present.
• Engage appropriate consultants to ensure proper airway management as appropriate.

Pediatric hospitalists should be able to:

• Exemplify responsible airway management and oxygen delivery when the clinical need arises.
• Acknowledge the importance of maintaining skills in airway management and oxygen delivery.
• Appreciate the importance of remaining current with relevant continuing education activities, including Pediatric Advanced Life Support (PALS).
• Exemplify and advocate for effective communication with the patient and the family/caregivers regarding the need for airway management, oxygen delivery, and the care plan.

In order to improve efficiency and quality within their organizations, pediatric hospitalists should:

• Collaborate with hospital administration to optimize appropriate utilization of oxygen therapies and oxygenation monitoring devices.
• Lead, coordinate, or participate in the development of hospital systems designed to detect patients with respiratory compromise early and provide an appropriate, rapid response.
• Lead, coordinate, or participate in educational opportunities and systems to improve airway skills and effective response for healthcare providers, including PALS training, the use of mock codes, and simulation training where available.
• Collaborate with subspecialists and hospital administration to establish a system of appropriate identification and response to patients with atypical anatomy and the presence of a critical airway.
• Work with hospital administration to ensure that age and size-appropriate airway and emergency equipment is available for each patient room and care area.
• Collaborate to create and sustain practices to reduce potential harms from HACs associated with use of respiratory devices.

Introduction

Respiratory distress and respiratory failure are encountered in a significant number of pediatric conditions in acute care and inpatient settings. Early identification and treatment of respiratory compromise remain critically important to the effective practice of pediatric hospital medicine. Pediatric hospitalists frequently encounter patients requiring oxygen and airway management and should be skilled in appropriate airway management and oxygen delivery in order to reduce respiratory related morbidity and mortality for hospitalized children.

Pediatric hospitalists should be able to:

• Describe the different modes of oxygen delivery, including nasal cannula, simple face mask, nonrebreather, and partial rebreather masks, and the approximate amount of oxygen delivered with each.
• Describe the indications for and uses of different types of airway equipment, including oropharyngeal, nasopharyngeal, laryngeal mask, and tracheal airways.
• Compare and contrast low flow and high flow oxygen delivery systems.
• Describe types of noninvasive ventilation such as continuous or bi-level pressure delivery systems, and discuss their indications for use, according to local practice.
• Describe the basic anatomy of the upper respiratory tract and the anatomic differences between infants, children, and adolescents.
• Discuss factors that may complicate airway management, including anatomic abnormalities of the face and oropharynx, neurologic impairment, and trauma.
• Distinguish between the use of oxygen delivery devices and airway management devices in the management of impending respiratory failure.
• Discuss the steps involved in assessing and securing a patient’s airway, including proper airway positioning, suctioning, selection and use of the appropriate airway equipment, and the use of adjunctive medications.
• List the items essential to have available at the bedside or in an emergency supply cart in the event of respiratory compromise, including suction, oxygen, oxygen delivery systems, pediatric sizes of advanced airway equipment, and resuscitation medications.
• Identify the various forms of monitoring related to assessment of oxygenation and ventilation, including cardiorespiratory monitors, pulse oximetry, capnography, and blood gas sampling.
• Summarize commonly encountered complications and hospital-acquired conditions (HACs) associated with use of oxygen delivery and airway management devices, attending to potential harms to the skin, airway, and lung.
• Describe and interpret blood gas results, including arterial, venous, and capillary.
• Identify the indications for consultation with an otorhinolaryngologist, anesthesiologist, intensivist, surgeon, or other subspecialist regarding airway management.

Pediatric hospitalists should be able to:

• Identify patients needing or at risk for needing airway management devices or oxygen delivery and initiate appropriate use.
• Order appropriate monitoring for patients receiving oxygen or using airway devices and correctly interpret monitor data.
• Correctly use standard head tilt and jaw thrust maneuvers to open a child’s airway.
• Select and use the appropriate method of oxygen delivery according to the clinical situation.
• Select the appropriate airway device and size and establish a secure airway when indicated.
• Utilize noninvasive ventilation when clinically indicated, according to local context.
• Use suction equipment to clear the airway as appropriate.
• Respond with appropriate corrective action when a tracheostomy tube becomes obstructed or dislodged in patients with mature tracts, according to local context.
• Wean oxygen proactively when the clinical situation allows.
• Implement a patient-specific plan for respiratory care in collaboration with nursing, respiratory therapy, subspecialists, and other healthcare providers.
• Implement a plan to ensure healthcare team awareness of a critical airway when present.
• Engage appropriate consultants to ensure proper airway management as appropriate.

Pediatric hospitalists should be able to:

• Exemplify responsible airway management and oxygen delivery when the clinical need arises.
• Acknowledge the importance of maintaining skills in airway management and oxygen delivery.
• Appreciate the importance of remaining current with relevant continuing education activities, including Pediatric Advanced Life Support (PALS).
• Exemplify and advocate for effective communication with the patient and the family/caregivers regarding the need for airway management, oxygen delivery, and the care plan.

In order to improve efficiency and quality within their organizations, pediatric hospitalists should:

• Collaborate with hospital administration to optimize appropriate utilization of oxygen therapies and oxygenation monitoring devices.
• Lead, coordinate, or participate in the development of hospital systems designed to detect patients with respiratory compromise early and provide an appropriate, rapid response.
• Lead, coordinate, or participate in educational opportunities and systems to improve airway skills and effective response for healthcare providers, including PALS training, the use of mock codes, and simulation training where available.
• Collaborate with subspecialists and hospital administration to establish a system of appropriate identification and response to patients with atypical anatomy and the presence of a critical airway.
• Work with hospital administration to ensure that age and size-appropriate airway and emergency equipment is available for each patient room and care area.
• Collaborate to create and sustain practices to reduce potential harms from HACs associated with use of respiratory devices.

Introduction

There is a growing body of evidence which shows that optimal nutrition improves outcomes in hospitalized children. Malnutrition refers to any disorder of nutritional status resulting from a deficiency or excess of nutrient intake, imbalance of essential nutrients, or impaired nutrient metabolism. Malnutrition occurs in up to half of hospitalized children in the United States but varies considerably by age and disease state. Malnutrition in hospitalized children is a risk factor for unfavorable clinical outcome, prolonged hospital stays, delayed recovery, and increased care costs. An understanding of the fundamental nutritional requirements of pediatric patients is essential to providing optimal care for hospitalized children. Pediatric hospitalists must be able to reliably perform objective nutritional assessments and manage frequently encountered nutritional problems. They are in an optimal position to detect disorders of nutrition and improve the nutritional status of hospitalized pediatric patients.

Pediatric hospitalists should be able to:

• Describe the normal growth patterns for children at various ages and the potential effect of malnutrition on growth.
• Describe the anthropometric measurements commonly used to assess acute and chronic nutritional status.
• Describe the basic nutritional requirements for hospitalized pediatric patients, based on gestational age, chronologic age, weight, activity level, and other characteristics.
• Compare and contrast the composition of human milk versus commonly used commercial formulas and explain why human milk is superior nutrition for infants.
• Describe the differences in composition of and clinical indications for commonly used commercial formulas, as well as protein hydrolysate and other specialty formulas.
• Compare and contrast the benefits and costs of blended foods versus commonly used enteral formulas as complete nutritional sources for children receiving gastric, duodenal, or jejunal tube feedings.
• List the indications for specific vitamin and mineral supplementation, including exclusive breastfeeding in infants less than 6 months, infants consuming less than 27 ounces of formula per day, chronic anti-epileptic therapy, food allergies resulting in extreme dietary restrictions, and others.
• List the factors that place hospitalized pediatric patients at risk for poor nutrition.
• Compare and contrast marasmus and kwashiorkor.
• Define the term protein-calorie malnutrition.
• List the signs and symptoms of common vitamin and mineral deficiencies including iron, calcium, zinc, and Vitamin D.
• Compare and contrast commonly encountered nutritional needs and risks between different types of eating disorders, including anorexia nervosa, bulimia nervosa, rumination, and Avoidant/Restrictive Food Intake Disorder (ARFID).
• Discuss the indications and contraindications for both enteral and parenteral nutrition and describe the complications associated with each.
• Describe the monitoring needs for pediatric patients on chronic enteral or parenteral nutrition, attending to electrolyte and mineral disturbances, growth, and other parameters.
• Discuss refeeding syndrome, the risk factors associated with its development, and the treatment for its most common manifestations.
• Explain the importance of nutrition screening, as well as the indications for consultation with a register dietician, gastroenterologist, mental health professional, or other subspecialist.
• Discuss the maintenance and supplemental needs of patients with commonly encountered metabolic/mitochondrial disorders and inborn errors of metabolism, including Galactosemia, Phenylketonuria, Maple Syrup Urine Disease, and Hereditary Fructose Intolerance.

Pediatric hospitalists should be able to:

• Assess and utilize anthropometric data to determine the presence, degree, and chronicity of malnutrition.
• Perform a focused history and physical examination, attending to details that may indicate a particular nutrient, vitamin, or mineral deficiency.
• Conduct a directed laboratory evaluation to obtain information about nutritional status and vitamin or mineral deficiencies, as indicated.
• Determine the basic caloric, protein, fat, and fluid requirements for hospitalized pediatric patients, for both maintenance needs and catch up growth.
• Provide educational and clinical staff support for lactating mothers, including those having trouble initiating or maintaining breastfeeding or milk supply or those with a breastfeeding complication, including nipple pain or compression, poor milk transfer, low supply, plugged ducts, or mastitis.
• Choose an appropriate formula, delivery device, and method of administration when enteral nutrition is required.
• Emphasize the importance of using enteral nutrition over the parenteral route whenever possible.
• Initiate and advance parenteral nutrition using the appropriate initial composition of parenteral nutrition solution, delivery device, and method of administration when required.
• Appropriately monitor laboratory values to ensure the efficacy of supplemental nutrition support and to screen for complications.
• Identify and treat complications of both enteral and parenteral nutrition, such as metabolic derangements, infection, and delivery device malfunction.
• Identify the signs of and effectively treat refeeding syndrome.
• Identify, treat, and/or consult appropriate specialties and services for children with eating disorders.
• Engage consultants, including registered dieticians, lactation, gastroenterologists, mental health professionals, and other subspecialists as indicated.
• Arrange an effective and safe transition of care from inpatient to outpatient providers, preserving the multidisciplinary nature of the nutrition care team when appropriate.
• Collaborate with the primary care provider and subspecialists to ensure coordinated, longitudinal care for children requiring specialized nutrition support.

Pediatric hospitalists should be able to:

• Realize the importance of screening for malnutrition and optimizing nutritional status for hospitalized pediatric patients.
• Reflect on the value of effective communication with patients, the family/caregivers, and healthcare providers regarding the role of adequate nutrition in achieving optimal clinical outcomes.
• Acknowledge the importance of collaboration with registered dieticians and subspecialists to devise and implement a nutrition care plan.

In order to improve efficiency and quality within their organizations, pediatric hospitalists should:

• Lead, coordinate, or participate in efforts to develop systems that support the initiation and maintenance of breastfeeding for infants.
• Collaborate with hospital administration, hospital staff, subspecialists, and other services/consultants to promote prompt nutritional screening for all hospitalized patients and multidisciplinary team care to address nutritional problems when identified.
• Lead, coordinate, or participate in the development and implementation of cost-effective, evidence-based care pathways to standardize the evaluation and management of nutritional issues in hospitalized children.

Introduction

There is a growing body of evidence which shows that optimal nutrition improves outcomes in hospitalized children. Malnutrition refers to any disorder of nutritional status resulting from a deficiency or excess of nutrient intake, imbalance of essential nutrients, or impaired nutrient metabolism. Malnutrition occurs in up to half of hospitalized children in the United States but varies considerably by age and disease state. Malnutrition in hospitalized children is a risk factor for unfavorable clinical outcome, prolonged hospital stays, delayed recovery, and increased care costs. An understanding of the fundamental nutritional requirements of pediatric patients is essential to providing optimal care for hospitalized children. Pediatric hospitalists must be able to reliably perform objective nutritional assessments and manage frequently encountered nutritional problems. They are in an optimal position to detect disorders of nutrition and improve the nutritional status of hospitalized pediatric patients.

Pediatric hospitalists should be able to:

• Describe the normal growth patterns for children at various ages and the potential effect of malnutrition on growth.
• Describe the anthropometric measurements commonly used to assess acute and chronic nutritional status.
• Describe the basic nutritional requirements for hospitalized pediatric patients, based on gestational age, chronologic age, weight, activity level, and other characteristics.
• Compare and contrast the composition of human milk versus commonly used commercial formulas and explain why human milk is superior nutrition for infants.
• Describe the differences in composition of and clinical indications for commonly used commercial formulas, as well as protein hydrolysate and other specialty formulas.
• Compare and contrast the benefits and costs of blended foods versus commonly used enteral formulas as complete nutritional sources for children receiving gastric, duodenal, or jejunal tube feedings.
• List the indications for specific vitamin and mineral supplementation, including exclusive breastfeeding in infants less than 6 months, infants consuming less than 27 ounces of formula per day, chronic anti-epileptic therapy, food allergies resulting in extreme dietary restrictions, and others.
• List the factors that place hospitalized pediatric patients at risk for poor nutrition.
• Compare and contrast marasmus and kwashiorkor.
• Define the term protein-calorie malnutrition.
• List the signs and symptoms of common vitamin and mineral deficiencies including iron, calcium, zinc, and Vitamin D.
• Compare and contrast commonly encountered nutritional needs and risks between different types of eating disorders, including anorexia nervosa, bulimia nervosa, rumination, and Avoidant/Restrictive Food Intake Disorder (ARFID).
• Discuss the indications and contraindications for both enteral and parenteral nutrition and describe the complications associated with each.
• Describe the monitoring needs for pediatric patients on chronic enteral or parenteral nutrition, attending to electrolyte and mineral disturbances, growth, and other parameters.
• Discuss refeeding syndrome, the risk factors associated with its development, and the treatment for its most common manifestations.
• Explain the importance of nutrition screening, as well as the indications for consultation with a register dietician, gastroenterologist, mental health professional, or other subspecialist.
• Discuss the maintenance and supplemental needs of patients with commonly encountered metabolic/mitochondrial disorders and inborn errors of metabolism, including Galactosemia, Phenylketonuria, Maple Syrup Urine Disease, and Hereditary Fructose Intolerance.

Pediatric hospitalists should be able to:

• Assess and utilize anthropometric data to determine the presence, degree, and chronicity of malnutrition.
• Perform a focused history and physical examination, attending to details that may indicate a particular nutrient, vitamin, or mineral deficiency.
• Conduct a directed laboratory evaluation to obtain information about nutritional status and vitamin or mineral deficiencies, as indicated.
• Determine the basic caloric, protein, fat, and fluid requirements for hospitalized pediatric patients, for both maintenance needs and catch up growth.
• Provide educational and clinical staff support for lactating mothers, including those having trouble initiating or maintaining breastfeeding or milk supply or those with a breastfeeding complication, including nipple pain or compression, poor milk transfer, low supply, plugged ducts, or mastitis.
• Choose an appropriate formula, delivery device, and method of administration when enteral nutrition is required.
• Emphasize the importance of using enteral nutrition over the parenteral route whenever possible.
• Initiate and advance parenteral nutrition using the appropriate initial composition of parenteral nutrition solution, delivery device, and method of administration when required.
• Appropriately monitor laboratory values to ensure the efficacy of supplemental nutrition support and to screen for complications.
• Identify and treat complications of both enteral and parenteral nutrition, such as metabolic derangements, infection, and delivery device malfunction.
• Identify the signs of and effectively treat refeeding syndrome.
• Identify, treat, and/or consult appropriate specialties and services for children with eating disorders.
• Engage consultants, including registered dieticians, lactation, gastroenterologists, mental health professionals, and other subspecialists as indicated.
• Arrange an effective and safe transition of care from inpatient to outpatient providers, preserving the multidisciplinary nature of the nutrition care team when appropriate.
• Collaborate with the primary care provider and subspecialists to ensure coordinated, longitudinal care for children requiring specialized nutrition support.

Pediatric hospitalists should be able to:

• Realize the importance of screening for malnutrition and optimizing nutritional status for hospitalized pediatric patients.
• Reflect on the value of effective communication with patients, the family/caregivers, and healthcare providers regarding the role of adequate nutrition in achieving optimal clinical outcomes.
• Acknowledge the importance of collaboration with registered dieticians and subspecialists to devise and implement a nutrition care plan.

In order to improve efficiency and quality within their organizations, pediatric hospitalists should:

• Lead, coordinate, or participate in efforts to develop systems that support the initiation and maintenance of breastfeeding for infants.
• Collaborate with hospital administration, hospital staff, subspecialists, and other services/consultants to promote prompt nutritional screening for all hospitalized patients and multidisciplinary team care to address nutritional problems when identified.
• Lead, coordinate, or participate in the development and implementation of cost-effective, evidence-based care pathways to standardize the evaluation and management of nutritional issues in hospitalized children.

Introduction

There is a growing body of evidence which shows that optimal nutrition improves outcomes in hospitalized children. Malnutrition refers to any disorder of nutritional status resulting from a deficiency or excess of nutrient intake, imbalance of essential nutrients, or impaired nutrient metabolism. Malnutrition occurs in up to half of hospitalized children in the United States but varies considerably by age and disease state. Malnutrition in hospitalized children is a risk factor for unfavorable clinical outcome, prolonged hospital stays, delayed recovery, and increased care costs. An understanding of the fundamental nutritional requirements of pediatric patients is essential to providing optimal care for hospitalized children. Pediatric hospitalists must be able to reliably perform objective nutritional assessments and manage frequently encountered nutritional problems. They are in an optimal position to detect disorders of nutrition and improve the nutritional status of hospitalized pediatric patients.

Pediatric hospitalists should be able to:

• Describe the normal growth patterns for children at various ages and the potential effect of malnutrition on growth.
• Describe the anthropometric measurements commonly used to assess acute and chronic nutritional status.
• Describe the basic nutritional requirements for hospitalized pediatric patients, based on gestational age, chronologic age, weight, activity level, and other characteristics.
• Compare and contrast the composition of human milk versus commonly used commercial formulas and explain why human milk is superior nutrition for infants.
• Describe the differences in composition of and clinical indications for commonly used commercial formulas, as well as protein hydrolysate and other specialty formulas.
• Compare and contrast the benefits and costs of blended foods versus commonly used enteral formulas as complete nutritional sources for children receiving gastric, duodenal, or jejunal tube feedings.
• List the indications for specific vitamin and mineral supplementation, including exclusive breastfeeding in infants less than 6 months, infants consuming less than 27 ounces of formula per day, chronic anti-epileptic therapy, food allergies resulting in extreme dietary restrictions, and others.
• List the factors that place hospitalized pediatric patients at risk for poor nutrition.
• Compare and contrast marasmus and kwashiorkor.
• Define the term protein-calorie malnutrition.
• List the signs and symptoms of common vitamin and mineral deficiencies including iron, calcium, zinc, and Vitamin D.
• Compare and contrast commonly encountered nutritional needs and risks between different types of eating disorders, including anorexia nervosa, bulimia nervosa, rumination, and Avoidant/Restrictive Food Intake Disorder (ARFID).
• Discuss the indications and contraindications for both enteral and parenteral nutrition and describe the complications associated with each.
• Describe the monitoring needs for pediatric patients on chronic enteral or parenteral nutrition, attending to electrolyte and mineral disturbances, growth, and other parameters.
• Discuss refeeding syndrome, the risk factors associated with its development, and the treatment for its most common manifestations.
• Explain the importance of nutrition screening, as well as the indications for consultation with a register dietician, gastroenterologist, mental health professional, or other subspecialist.
• Discuss the maintenance and supplemental needs of patients with commonly encountered metabolic/mitochondrial disorders and inborn errors of metabolism, including Galactosemia, Phenylketonuria, Maple Syrup Urine Disease, and Hereditary Fructose Intolerance.

Pediatric hospitalists should be able to:

• Assess and utilize anthropometric data to determine the presence, degree, and chronicity of malnutrition.
• Perform a focused history and physical examination, attending to details that may indicate a particular nutrient, vitamin, or mineral deficiency.
• Conduct a directed laboratory evaluation to obtain information about nutritional status and vitamin or mineral deficiencies, as indicated.
• Determine the basic caloric, protein, fat, and fluid requirements for hospitalized pediatric patients, for both maintenance needs and catch up growth.
• Provide educational and clinical staff support for lactating mothers, including those having trouble initiating or maintaining breastfeeding or milk supply or those with a breastfeeding complication, including nipple pain or compression, poor milk transfer, low supply, plugged ducts, or mastitis.
• Choose an appropriate formula, delivery device, and method of administration when enteral nutrition is required.
• Emphasize the importance of using enteral nutrition over the parenteral route whenever possible.
• Initiate and advance parenteral nutrition using the appropriate initial composition of parenteral nutrition solution, delivery device, and method of administration when required.
• Appropriately monitor laboratory values to ensure the efficacy of supplemental nutrition support and to screen for complications.
• Identify and treat complications of both enteral and parenteral nutrition, such as metabolic derangements, infection, and delivery device malfunction.
• Identify the signs of and effectively treat refeeding syndrome.
• Identify, treat, and/or consult appropriate specialties and services for children with eating disorders.
• Engage consultants, including registered dieticians, lactation, gastroenterologists, mental health professionals, and other subspecialists as indicated.
• Arrange an effective and safe transition of care from inpatient to outpatient providers, preserving the multidisciplinary nature of the nutrition care team when appropriate.
• Collaborate with the primary care provider and subspecialists to ensure coordinated, longitudinal care for children requiring specialized nutrition support.

Pediatric hospitalists should be able to:

• Realize the importance of screening for malnutrition and optimizing nutritional status for hospitalized pediatric patients.
• Reflect on the value of effective communication with patients, the family/caregivers, and healthcare providers regarding the role of adequate nutrition in achieving optimal clinical outcomes.
• Acknowledge the importance of collaboration with registered dieticians and subspecialists to devise and implement a nutrition care plan.

In order to improve efficiency and quality within their organizations, pediatric hospitalists should:

• Lead, coordinate, or participate in efforts to develop systems that support the initiation and maintenance of breastfeeding for infants.
• Collaborate with hospital administration, hospital staff, subspecialists, and other services/consultants to promote prompt nutritional screening for all hospitalized patients and multidisciplinary team care to address nutritional problems when identified.
• Lead, coordinate, or participate in the development and implementation of cost-effective, evidence-based care pathways to standardize the evaluation and management of nutritional issues in hospitalized children.

Introduction

Noninvasive monitoring provides objective data that, when coupled with clinical assessments, is helpful in making therapeutic and diagnostic decisions. Knowledge of noninvasive monitoring techniques is necessary for accurate interpretation of the data generated. While the appropriate use of noninvasive monitoring is not controversial, there is increasing recognition of the importance of being selective in choosing the correct type and level of monitoring. Indiscriminant monitoring can lead to alarm fatigue, medical errors, patient harm, and may unnecessarily prolong the length of the hospitalization. Consequently, pediatric hospitalists should understand the various types of noninvasive monitoring techniques available, as well as the indications for and limitations of each.

Pediatric hospitalists should be able to:

• List the different types of noninvasive monitoring available and describe the indications for each.
• Compare and contrast the types and level of monitoring available on the inpatient ward compared to the intensive care unit or other care settings, attending to local context.
• Describe the proper procedures for common noninvasive monitoring techniques, including vital sign measurement, cardiopulmonary monitoring, pulse oximetry, capnography, and cardiac telemetry.
• List the limitations or complications associated with common noninvasive monitoring techniques, such as inadequate waveform for pulse oximetry.
• Compare and contrast the indications for cardiopulmonary monitoring and cardiac telemetry.
• Discuss the importance of accurate and timely interpretation of information generated by monitoring devices, as well as the importance of an immediate response when abnormal data is noted.
• Compare and contrast patients who need ongoing monitoring versus discontinuation of monitoring based on clinical course and established evidence when available.

Pediatric hospitalists should be able to:

• Select the type and level of monitoring needed based on the clinical situation and medical complexity of the patient in order to provide necessary data while limiting false alarms.
• Identify the need for a higher or lower level of monitoring as changes in the clinical status occur, including when transfers between clinical settings are indicated as a result.
• Ensure proper placement of monitoring equipment and execution of proper technique (including manual blood pressure measurement), in order to obtain accurate data.
• Interpret monitor data and respond with appropriate actions.

Pediatric hospitalists should be able to:

• Recognize that not all patients require intense monitoring and promote the judicious use of monitoring based on clinical assessments of patients.
• Recognize the importance of effective communication with patients and the family/caregivers regarding the use or discontinuation of noninvasive monitoring and how it relates to the care plan.
• Acknowledge the value of collaboration with nurses, respiratory therapists, subspecialists, and other healthcare providers to determine the appropriate level of monitoring and the corresponding care setting, especially when clinical changes occur.

In order to improve efficiency and quality within their organizations, pediatric hospitalists should:

• Lead, coordinate, and participate in the development and implementation of cost-effective, safe, evidence-based procedures and policies related to noninvasive monitoring, including implementation of strategies to limit alarm fatigue.
• Work with hospital administration, biomedical engineering, and others to obtain high quality and reliable monitoring equipment.
• Lead, coordinate, or participate in the development and implementation of a system for review of family/caregiver and healthcare provider satisfaction with monitoring strategies.

Introduction

Noninvasive monitoring provides objective data that, when coupled with clinical assessments, is helpful in making therapeutic and diagnostic decisions. Knowledge of noninvasive monitoring techniques is necessary for accurate interpretation of the data generated. While the appropriate use of noninvasive monitoring is not controversial, there is increasing recognition of the importance of being selective in choosing the correct type and level of monitoring. Indiscriminant monitoring can lead to alarm fatigue, medical errors, patient harm, and may unnecessarily prolong the length of the hospitalization. Consequently, pediatric hospitalists should understand the various types of noninvasive monitoring techniques available, as well as the indications for and limitations of each.

Pediatric hospitalists should be able to:

• List the different types of noninvasive monitoring available and describe the indications for each.
• Compare and contrast the types and level of monitoring available on the inpatient ward compared to the intensive care unit or other care settings, attending to local context.
• Describe the proper procedures for common noninvasive monitoring techniques, including vital sign measurement, cardiopulmonary monitoring, pulse oximetry, capnography, and cardiac telemetry.
• List the limitations or complications associated with common noninvasive monitoring techniques, such as inadequate waveform for pulse oximetry.
• Compare and contrast the indications for cardiopulmonary monitoring and cardiac telemetry.
• Discuss the importance of accurate and timely interpretation of information generated by monitoring devices, as well as the importance of an immediate response when abnormal data is noted.
• Compare and contrast patients who need ongoing monitoring versus discontinuation of monitoring based on clinical course and established evidence when available.

Pediatric hospitalists should be able to:

• Select the type and level of monitoring needed based on the clinical situation and medical complexity of the patient in order to provide necessary data while limiting false alarms.
• Identify the need for a higher or lower level of monitoring as changes in the clinical status occur, including when transfers between clinical settings are indicated as a result.
• Ensure proper placement of monitoring equipment and execution of proper technique (including manual blood pressure measurement), in order to obtain accurate data.
• Interpret monitor data and respond with appropriate actions.

Pediatric hospitalists should be able to:

• Recognize that not all patients require intense monitoring and promote the judicious use of monitoring based on clinical assessments of patients.
• Recognize the importance of effective communication with patients and the family/caregivers regarding the use or discontinuation of noninvasive monitoring and how it relates to the care plan.
• Acknowledge the value of collaboration with nurses, respiratory therapists, subspecialists, and other healthcare providers to determine the appropriate level of monitoring and the corresponding care setting, especially when clinical changes occur.

In order to improve efficiency and quality within their organizations, pediatric hospitalists should:

• Lead, coordinate, and participate in the development and implementation of cost-effective, safe, evidence-based procedures and policies related to noninvasive monitoring, including implementation of strategies to limit alarm fatigue.
• Work with hospital administration, biomedical engineering, and others to obtain high quality and reliable monitoring equipment.
• Lead, coordinate, or participate in the development and implementation of a system for review of family/caregiver and healthcare provider satisfaction with monitoring strategies.

Introduction

Noninvasive monitoring provides objective data that, when coupled with clinical assessments, is helpful in making therapeutic and diagnostic decisions. Knowledge of noninvasive monitoring techniques is necessary for accurate interpretation of the data generated. While the appropriate use of noninvasive monitoring is not controversial, there is increasing recognition of the importance of being selective in choosing the correct type and level of monitoring. Indiscriminant monitoring can lead to alarm fatigue, medical errors, patient harm, and may unnecessarily prolong the length of the hospitalization. Consequently, pediatric hospitalists should understand the various types of noninvasive monitoring techniques available, as well as the indications for and limitations of each.

Pediatric hospitalists should be able to:

• List the different types of noninvasive monitoring available and describe the indications for each.
• Compare and contrast the types and level of monitoring available on the inpatient ward compared to the intensive care unit or other care settings, attending to local context.
• Describe the proper procedures for common noninvasive monitoring techniques, including vital sign measurement, cardiopulmonary monitoring, pulse oximetry, capnography, and cardiac telemetry.
• List the limitations or complications associated with common noninvasive monitoring techniques, such as inadequate waveform for pulse oximetry.
• Compare and contrast the indications for cardiopulmonary monitoring and cardiac telemetry.
• Discuss the importance of accurate and timely interpretation of information generated by monitoring devices, as well as the importance of an immediate response when abnormal data is noted.
• Compare and contrast patients who need ongoing monitoring versus discontinuation of monitoring based on clinical course and established evidence when available.

Pediatric hospitalists should be able to:

• Select the type and level of monitoring needed based on the clinical situation and medical complexity of the patient in order to provide necessary data while limiting false alarms.
• Identify the need for a higher or lower level of monitoring as changes in the clinical status occur, including when transfers between clinical settings are indicated as a result.
• Ensure proper placement of monitoring equipment and execution of proper technique (including manual blood pressure measurement), in order to obtain accurate data.
• Interpret monitor data and respond with appropriate actions.

Pediatric hospitalists should be able to:

• Recognize that not all patients require intense monitoring and promote the judicious use of monitoring based on clinical assessments of patients.
• Recognize the importance of effective communication with patients and the family/caregivers regarding the use or discontinuation of noninvasive monitoring and how it relates to the care plan.
• Acknowledge the value of collaboration with nurses, respiratory therapists, subspecialists, and other healthcare providers to determine the appropriate level of monitoring and the corresponding care setting, especially when clinical changes occur.

In order to improve efficiency and quality within their organizations, pediatric hospitalists should:

• Lead, coordinate, and participate in the development and implementation of cost-effective, safe, evidence-based procedures and policies related to noninvasive monitoring, including implementation of strategies to limit alarm fatigue.
• Work with hospital administration, biomedical engineering, and others to obtain high quality and reliable monitoring equipment.
• Lead, coordinate, or participate in the development and implementation of a system for review of family/caregiver and healthcare provider satisfaction with monitoring strategies.

Introduction

Lumbar puncture (also called “spinal tap”) is a common procedure that involves obtaining cerebral spinal fluid via needle from the spinal canal. It is generally performed for diagnostic purposes, most often to assess for central nervous system infections, including meningitis. Other indications include the evaluation of idiopathic intracranial hypertension (IIH), altered mental status or neurologic deterioration, subarachnoid hemorrhage, and demyelinating diseases such as Guillain Barré. Lumbar puncture may also be performed for therapeutic purposes, including management of IIH or administration of intrathecal medications. A lumbar puncture often elicits great concern from both patients and the family/caregivers due to concerns of pain and a misunderstanding of risk to the spinal cord. Adequate discussion with patients and the family/caregivers and appropriate use of topical anesthesia, anxiolysis, or sedation can create the environment needed for a successful procedure. Pediatric hospitalists frequently encounter patients requiring lumbar puncture and should be adept at performing lumbar puncture in all appropriately selected pediatric patients.

Pediatric hospitalists should be able to:

• List the indications for lumbar puncture, such as confirmation of pleocytosis or pathogen, therapeutic removal of fluid, assessment of response to treatment, performance of neurometabolic studies, and others.
• Review the basic anatomy of the spine and spinal column.
• List the indications for obtaining an imaging study of the brain or spinal cord prior to performing a lumbar puncture.
• Describe the relative contraindications to lumbar puncture, such as pre-existing ventriculoperitoneal shunt, previous spinal surgeries, and others, and discuss the options for safely obtaining cerebrospinal fluid in these patients.
• List the absolute contraindications to lumbar puncture, such as increased intracranial pressure, unstable cardiorespiratory status, unstable coagulopathies, and others.
• Describe the risks and complications of lumbar puncture attending to infection, bleeding, nerve injury, pain, post-procedure headache, and others.
• Summarize factors that may increase risk for complications, including age, disease process, and anatomy.
• Review the steps in performing a lumbar puncture, attending to aspects such as infection control, patient identification, positioning options, monitoring, presence of the family/caregivers, and others.
• Discuss the roles of each member of the healthcare team during lumbar puncture, attending to responsibility for performing proper level of monitoring to maximize safety, timeout, documentation, specimen labeling and transport to the laboratory, and communication with patients and the family/caregivers.

Pediatric hospitalists should be able to:

• Perform a pre-procedural evaluation to determine risks and benefits of lumbar puncture.
• Obtain informed consent from the family/caregivers.
• Order and ensure proper performance of procedural sedation if indicated, including assurance of adequate staff presence for both the lumbar puncture and the sedation.
• Demonstrate proficiency in performance of lumbar puncture on infants, children, and adolescents.
• Identify the need for and efficiently offer education to healthcare providers on proper techniques for holding and calming patients before, during, and after lumbar puncture attempts.
• Adhere to infection control practices.
• Order appropriate monitoring and correctly interpret monitor data.
• Identify complications and respond with appropriate actions.
• Use the pressure manometer as appropriate.
• Identify the need for and efficiently access appropriate consultants and support services for assistance with pain management, sedation, and performance of a lumbar puncture, as indicated.

Pediatric hospitalists should be able to:

• Appreciate the importance of working collaboratively with hospital staff and subspecialists to ensure coordinated planning and performance of lumbar punctures.
• Realize the importance of effective communication with patients and the family/caregivers regarding the indications for, risks, benefits, and steps of the procedure.
• Role model and advocate for strict adherence to infection control practices.

In order to improve efficiency and quality within their organizations, pediatric hospitalists should:

• Lead, coordinate, or participate in the development and implementation of cost-effective, safe, evidence-based procedures and policies for performance of lumbar punctures for children.
• Work with hospital administration, hospital staff, and others to develop and implement standardized documentation tools for the procedure.
• Lead, coordinate, or participate in the development and implementation of a system for review of family/caregiver and healthcare provider satisfaction into procedural strategies.
• Lead, coordinate, or participate in the development and implementation of educational initiatives designed to teach the proper technique for lumbar puncture to trainees and other healthcare providers.

Introduction

Lumbar puncture (also called “spinal tap”) is a common procedure that involves obtaining cerebral spinal fluid via needle from the spinal canal. It is generally performed for diagnostic purposes, most often to assess for central nervous system infections, including meningitis. Other indications include the evaluation of idiopathic intracranial hypertension (IIH), altered mental status or neurologic deterioration, subarachnoid hemorrhage, and demyelinating diseases such as Guillain Barré. Lumbar puncture may also be performed for therapeutic purposes, including management of IIH or administration of intrathecal medications. A lumbar puncture often elicits great concern from both patients and the family/caregivers due to concerns of pain and a misunderstanding of risk to the spinal cord. Adequate discussion with patients and the family/caregivers and appropriate use of topical anesthesia, anxiolysis, or sedation can create the environment needed for a successful procedure. Pediatric hospitalists frequently encounter patients requiring lumbar puncture and should be adept at performing lumbar puncture in all appropriately selected pediatric patients.

Pediatric hospitalists should be able to:

• List the indications for lumbar puncture, such as confirmation of pleocytosis or pathogen, therapeutic removal of fluid, assessment of response to treatment, performance of neurometabolic studies, and others.
• Review the basic anatomy of the spine and spinal column.
• List the indications for obtaining an imaging study of the brain or spinal cord prior to performing a lumbar puncture.
• Describe the relative contraindications to lumbar puncture, such as pre-existing ventriculoperitoneal shunt, previous spinal surgeries, and others, and discuss the options for safely obtaining cerebrospinal fluid in these patients.
• List the absolute contraindications to lumbar puncture, such as increased intracranial pressure, unstable cardiorespiratory status, unstable coagulopathies, and others.
• Describe the risks and complications of lumbar puncture attending to infection, bleeding, nerve injury, pain, post-procedure headache, and others.
• Summarize factors that may increase risk for complications, including age, disease process, and anatomy.
• Review the steps in performing a lumbar puncture, attending to aspects such as infection control, patient identification, positioning options, monitoring, presence of the family/caregivers, and others.
• Discuss the roles of each member of the healthcare team during lumbar puncture, attending to responsibility for performing proper level of monitoring to maximize safety, timeout, documentation, specimen labeling and transport to the laboratory, and communication with patients and the family/caregivers.

Pediatric hospitalists should be able to:

• Perform a pre-procedural evaluation to determine risks and benefits of lumbar puncture.
• Obtain informed consent from the family/caregivers.
• Order and ensure proper performance of procedural sedation if indicated, including assurance of adequate staff presence for both the lumbar puncture and the sedation.
• Demonstrate proficiency in performance of lumbar puncture on infants, children, and adolescents.
• Identify the need for and efficiently offer education to healthcare providers on proper techniques for holding and calming patients before, during, and after lumbar puncture attempts.
• Adhere to infection control practices.
• Order appropriate monitoring and correctly interpret monitor data.
• Identify complications and respond with appropriate actions.
• Use the pressure manometer as appropriate.
• Identify the need for and efficiently access appropriate consultants and support services for assistance with pain management, sedation, and performance of a lumbar puncture, as indicated.

Pediatric hospitalists should be able to:

• Appreciate the importance of working collaboratively with hospital staff and subspecialists to ensure coordinated planning and performance of lumbar punctures.
• Realize the importance of effective communication with patients and the family/caregivers regarding the indications for, risks, benefits, and steps of the procedure.
• Role model and advocate for strict adherence to infection control practices.

In order to improve efficiency and quality within their organizations, pediatric hospitalists should:

• Lead, coordinate, or participate in the development and implementation of cost-effective, safe, evidence-based procedures and policies for performance of lumbar punctures for children.
• Work with hospital administration, hospital staff, and others to develop and implement standardized documentation tools for the procedure.
• Lead, coordinate, or participate in the development and implementation of a system for review of family/caregiver and healthcare provider satisfaction into procedural strategies.
• Lead, coordinate, or participate in the development and implementation of educational initiatives designed to teach the proper technique for lumbar puncture to trainees and other healthcare providers.

Introduction

Lumbar puncture (also called “spinal tap”) is a common procedure that involves obtaining cerebral spinal fluid via needle from the spinal canal. It is generally performed for diagnostic purposes, most often to assess for central nervous system infections, including meningitis. Other indications include the evaluation of idiopathic intracranial hypertension (IIH), altered mental status or neurologic deterioration, subarachnoid hemorrhage, and demyelinating diseases such as Guillain Barré. Lumbar puncture may also be performed for therapeutic purposes, including management of IIH or administration of intrathecal medications. A lumbar puncture often elicits great concern from both patients and the family/caregivers due to concerns of pain and a misunderstanding of risk to the spinal cord. Adequate discussion with patients and the family/caregivers and appropriate use of topical anesthesia, anxiolysis, or sedation can create the environment needed for a successful procedure. Pediatric hospitalists frequently encounter patients requiring lumbar puncture and should be adept at performing lumbar puncture in all appropriately selected pediatric patients.

Pediatric hospitalists should be able to:

• List the indications for lumbar puncture, such as confirmation of pleocytosis or pathogen, therapeutic removal of fluid, assessment of response to treatment, performance of neurometabolic studies, and others.
• Review the basic anatomy of the spine and spinal column.
• List the indications for obtaining an imaging study of the brain or spinal cord prior to performing a lumbar puncture.
• Describe the relative contraindications to lumbar puncture, such as pre-existing ventriculoperitoneal shunt, previous spinal surgeries, and others, and discuss the options for safely obtaining cerebrospinal fluid in these patients.
• List the absolute contraindications to lumbar puncture, such as increased intracranial pressure, unstable cardiorespiratory status, unstable coagulopathies, and others.
• Describe the risks and complications of lumbar puncture attending to infection, bleeding, nerve injury, pain, post-procedure headache, and others.
• Summarize factors that may increase risk for complications, including age, disease process, and anatomy.
• Review the steps in performing a lumbar puncture, attending to aspects such as infection control, patient identification, positioning options, monitoring, presence of the family/caregivers, and others.
• Discuss the roles of each member of the healthcare team during lumbar puncture, attending to responsibility for performing proper level of monitoring to maximize safety, timeout, documentation, specimen labeling and transport to the laboratory, and communication with patients and the family/caregivers.

Pediatric hospitalists should be able to:

• Perform a pre-procedural evaluation to determine risks and benefits of lumbar puncture.
• Obtain informed consent from the family/caregivers.
• Order and ensure proper performance of procedural sedation if indicated, including assurance of adequate staff presence for both the lumbar puncture and the sedation.
• Demonstrate proficiency in performance of lumbar puncture on infants, children, and adolescents.
• Identify the need for and efficiently offer education to healthcare providers on proper techniques for holding and calming patients before, during, and after lumbar puncture attempts.
• Adhere to infection control practices.
• Order appropriate monitoring and correctly interpret monitor data.
• Identify complications and respond with appropriate actions.
• Use the pressure manometer as appropriate.
• Identify the need for and efficiently access appropriate consultants and support services for assistance with pain management, sedation, and performance of a lumbar puncture, as indicated.

Pediatric hospitalists should be able to:

• Appreciate the importance of working collaboratively with hospital staff and subspecialists to ensure coordinated planning and performance of lumbar punctures.
• Realize the importance of effective communication with patients and the family/caregivers regarding the indications for, risks, benefits, and steps of the procedure.
• Role model and advocate for strict adherence to infection control practices.

In order to improve efficiency and quality within their organizations, pediatric hospitalists should:

• Lead, coordinate, or participate in the development and implementation of cost-effective, safe, evidence-based procedures and policies for performance of lumbar punctures for children.
• Work with hospital administration, hospital staff, and others to develop and implement standardized documentation tools for the procedure.
• Lead, coordinate, or participate in the development and implementation of a system for review of family/caregiver and healthcare provider satisfaction into procedural strategies.
• Lead, coordinate, or participate in the development and implementation of educational initiatives designed to teach the proper technique for lumbar puncture to trainees and other healthcare providers.

Introduction

Intravenous (IV) line placement is the most common procedure performed on hospitalized children. Common indications include fluid resuscitation, parenteral medication, or nutrition delivery. Pediatric hospitalists should be knowledgeable about obtaining peripheral IV access in all pediatric patients and IV or intraosseous (IO) access in critically ill patients. Although not a requirement, many pediatric hospitalists may also obtain skills in the placement of central venous catheters and peripherally inserted central catheters (PICC). Pediatric hospitalists may also be called upon to obtain venous and arterial blood samples from pediatric patients. Preparation and counseling of the patient and family/caregivers, along with the appropriate use of pharmacologic and nonpharmacologic anxiolysis and pain control, can create the environment needed for a successful procedure.

Pediatric hospitalists should be able to:

• List the indications for IV access, such as rehydration, resuscitation, parenteral administration of medications or nutrition, and others.
• Compare and contrast the risks and benefits of using peripheral versus central sites for IV access, including indications and complications for each.
• Describe the indications, risks, benefits, and alternatives for PICC placement, including prolonged medication and/or nutrition needs.
• Compare and contrast risks and benefits of PICC versus midline central catheters and appropriate indications for each.
• Describe common complications of both peripheral and central IV access, including infiltration, bleeding, infection, and venous thrombosis.
• State the indications and contraindications for IO access.
• Discuss how factors such as age, disease process, and individual patient anatomy influence the choice of IV site.
• Summarize current literature and national best practices regarding avoidance of catheter-related bloodstream infections.
• Discuss strategies to minimize the number of IV attempts and common complications from multiple IV attempts.
• Describe use of modalities, such as vein-finding illuminators and ultrasound guidance, which can lead to higher rates of procedural success.
• Review the common radiographic modalities used to assess proper PICC placement and function.
• Review the options for procedural pain and sedation management by age and developmental stage, including pharmacologic and nonpharmacologic interventions.
• Review the indications for subspecialty consultation for IV access or blood sampling.
• Describe the contraindications for use of certain venous sites for IV access or phlebotomy (such as hemodialysis catheters, limb with neurovascular compromise, jugular vein with a neighboring ventriculo-peritoneal shunt, and others.)
• List the indications for arterial blood sampling.
• Describe the proper method for and common complications of obtaining venous and arterial blood samples.

Pediatric hospitalists should be able to:

• Perform a pre-procedural evaluation to determine risks and benefits of IV placement.
• Assess the need for and order appropriate pain and sedation medication and nonmedication interventions.
• Demonstrate the ability to obtain IV access on children of all ages via accessing appropriate personnel or safe performance of the procedure, according to local practice parameters.
• Obtain venous and arterial blood sampling (phlebotomy), with and without IV access, via accessing appropriate personnel or safe performance of the procedure, according to local practice parameters.
• Identify proper techniques for holding and calming patients before, during, and after access attempts and educate other healthcare providers in those techniques.
• Adhere to infection control practices.
• Utilize available modalities where available, such as vein-finding illuminators and ultrasound guidance, to achieve higher rates of procedural success.
• Demonstrate proficiency with intraosseous needle placement as evidenced by successful insertion of the IO needle in a simulated mock code situation.
• Identify barriers to efficient, effective IV access and engage subspecialists, including interventional radiology, anesthesiology, and surgery, to assist as appropriate.
• Identify common complications of IVs and blood sampling and respond with appropriate actions.
• Identify and initiate actions to limit unnecessary intravenous access or sampling by using strategies such as batching of lab tests, transition to oral medication, enteral rehydration, discouraging routine daily lab draws, and daily documentation of need for intravenous access.
• Obtain central venous access and PICCs when indicated via accessing appropriate consultants or safe performance of the procedure, according to local practice parameters.
• Demonstrate proficiency in addressing complications associated with peripheral and central lines (such as infiltrations, clots, displacements, and others) by prompt identification of the problem, initiation of indicated therapy, and consultation with appropriate subspecialists as indicated.

Pediatric hospitalists should be able to:

• Exemplify effective communication with patients and the family/caregivers regarding the indications for, and risks, benefits, and steps of the procedure.
• Role model and advocate for safety during procedures, by strict adherence to infection control practices and use of the “time-out for safety” verification process.
• Acknowledge the importance of revising the IV access plan as appropriate given patient and system limitations.
• Recognize the importance of limiting attempts at IV access in young children, with a need for an alternative plan when indicated.

In order to improve efficiency and quality within their organizations, pediatric hospitalists should:

• Lead, coordinate, or participate in the development and implementation of cost-effective, safe, evidence-based procedures and policies for IV access, adhering to national guidelines for infection control.
• Collaborate with hospital administration and clinical leaders to ensure adherence to modern procedural sedation and pain control guidelines, including limiting IV access attempts when an alternative plan is clinically feasible.
• Lead, coordinate, or participate in the development and implementation of a system for review of the efficacy, efficiency, and outcomes of intravenous access procedures.
• Lead, coordinate, or participate in the development and implementation of a system for review of family/caregiver and healthcare provider satisfaction related to venous access procedures.

Introduction

Intravenous (IV) line placement is the most common procedure performed on hospitalized children. Common indications include fluid resuscitation, parenteral medication, or nutrition delivery. Pediatric hospitalists should be knowledgeable about obtaining peripheral IV access in all pediatric patients and IV or intraosseous (IO) access in critically ill patients. Although not a requirement, many pediatric hospitalists may also obtain skills in the placement of central venous catheters and peripherally inserted central catheters (PICC). Pediatric hospitalists may also be called upon to obtain venous and arterial blood samples from pediatric patients. Preparation and counseling of the patient and family/caregivers, along with the appropriate use of pharmacologic and nonpharmacologic anxiolysis and pain control, can create the environment needed for a successful procedure.

Pediatric hospitalists should be able to:

• List the indications for IV access, such as rehydration, resuscitation, parenteral administration of medications or nutrition, and others.
• Compare and contrast the risks and benefits of using peripheral versus central sites for IV access, including indications and complications for each.
• Describe the indications, risks, benefits, and alternatives for PICC placement, including prolonged medication and/or nutrition needs.
• Compare and contrast risks and benefits of PICC versus midline central catheters and appropriate indications for each.
• Describe common complications of both peripheral and central IV access, including infiltration, bleeding, infection, and venous thrombosis.
• State the indications and contraindications for IO access.
• Discuss how factors such as age, disease process, and individual patient anatomy influence the choice of IV site.
• Summarize current literature and national best practices regarding avoidance of catheter-related bloodstream infections.
• Discuss strategies to minimize the number of IV attempts and common complications from multiple IV attempts.
• Describe use of modalities, such as vein-finding illuminators and ultrasound guidance, which can lead to higher rates of procedural success.
• Review the common radiographic modalities used to assess proper PICC placement and function.
• Review the options for procedural pain and sedation management by age and developmental stage, including pharmacologic and nonpharmacologic interventions.
• Review the indications for subspecialty consultation for IV access or blood sampling.
• Describe the contraindications for use of certain venous sites for IV access or phlebotomy (such as hemodialysis catheters, limb with neurovascular compromise, jugular vein with a neighboring ventriculo-peritoneal shunt, and others.)
• List the indications for arterial blood sampling.
• Describe the proper method for and common complications of obtaining venous and arterial blood samples.

Pediatric hospitalists should be able to:

• Perform a pre-procedural evaluation to determine risks and benefits of IV placement.
• Assess the need for and order appropriate pain and sedation medication and nonmedication interventions.
• Demonstrate the ability to obtain IV access on children of all ages via accessing appropriate personnel or safe performance of the procedure, according to local practice parameters.
• Obtain venous and arterial blood sampling (phlebotomy), with and without IV access, via accessing appropriate personnel or safe performance of the procedure, according to local practice parameters.
• Identify proper techniques for holding and calming patients before, during, and after access attempts and educate other healthcare providers in those techniques.
• Adhere to infection control practices.
• Utilize available modalities where available, such as vein-finding illuminators and ultrasound guidance, to achieve higher rates of procedural success.
• Demonstrate proficiency with intraosseous needle placement as evidenced by successful insertion of the IO needle in a simulated mock code situation.
• Identify barriers to efficient, effective IV access and engage subspecialists, including interventional radiology, anesthesiology, and surgery, to assist as appropriate.
• Identify common complications of IVs and blood sampling and respond with appropriate actions.
• Identify and initiate actions to limit unnecessary intravenous access or sampling by using strategies such as batching of lab tests, transition to oral medication, enteral rehydration, discouraging routine daily lab draws, and daily documentation of need for intravenous access.
• Obtain central venous access and PICCs when indicated via accessing appropriate consultants or safe performance of the procedure, according to local practice parameters.
• Demonstrate proficiency in addressing complications associated with peripheral and central lines (such as infiltrations, clots, displacements, and others) by prompt identification of the problem, initiation of indicated therapy, and consultation with appropriate subspecialists as indicated.

Pediatric hospitalists should be able to:

• Exemplify effective communication with patients and the family/caregivers regarding the indications for, and risks, benefits, and steps of the procedure.
• Role model and advocate for safety during procedures, by strict adherence to infection control practices and use of the “time-out for safety” verification process.
• Acknowledge the importance of revising the IV access plan as appropriate given patient and system limitations.
• Recognize the importance of limiting attempts at IV access in young children, with a need for an alternative plan when indicated.

In order to improve efficiency and quality within their organizations, pediatric hospitalists should:

• Lead, coordinate, or participate in the development and implementation of cost-effective, safe, evidence-based procedures and policies for IV access, adhering to national guidelines for infection control.
• Collaborate with hospital administration and clinical leaders to ensure adherence to modern procedural sedation and pain control guidelines, including limiting IV access attempts when an alternative plan is clinically feasible.
• Lead, coordinate, or participate in the development and implementation of a system for review of the efficacy, efficiency, and outcomes of intravenous access procedures.
• Lead, coordinate, or participate in the development and implementation of a system for review of family/caregiver and healthcare provider satisfaction related to venous access procedures.

Introduction

Intravenous (IV) line placement is the most common procedure performed on hospitalized children. Common indications include fluid resuscitation, parenteral medication, or nutrition delivery. Pediatric hospitalists should be knowledgeable about obtaining peripheral IV access in all pediatric patients and IV or intraosseous (IO) access in critically ill patients. Although not a requirement, many pediatric hospitalists may also obtain skills in the placement of central venous catheters and peripherally inserted central catheters (PICC). Pediatric hospitalists may also be called upon to obtain venous and arterial blood samples from pediatric patients. Preparation and counseling of the patient and family/caregivers, along with the appropriate use of pharmacologic and nonpharmacologic anxiolysis and pain control, can create the environment needed for a successful procedure.

Pediatric hospitalists should be able to:

• List the indications for IV access, such as rehydration, resuscitation, parenteral administration of medications or nutrition, and others.
• Compare and contrast the risks and benefits of using peripheral versus central sites for IV access, including indications and complications for each.
• Describe the indications, risks, benefits, and alternatives for PICC placement, including prolonged medication and/or nutrition needs.
• Compare and contrast risks and benefits of PICC versus midline central catheters and appropriate indications for each.
• Describe common complications of both peripheral and central IV access, including infiltration, bleeding, infection, and venous thrombosis.
• State the indications and contraindications for IO access.
• Discuss how factors such as age, disease process, and individual patient anatomy influence the choice of IV site.
• Summarize current literature and national best practices regarding avoidance of catheter-related bloodstream infections.
• Discuss strategies to minimize the number of IV attempts and common complications from multiple IV attempts.
• Describe use of modalities, such as vein-finding illuminators and ultrasound guidance, which can lead to higher rates of procedural success.
• Review the common radiographic modalities used to assess proper PICC placement and function.
• Review the options for procedural pain and sedation management by age and developmental stage, including pharmacologic and nonpharmacologic interventions.
• Review the indications for subspecialty consultation for IV access or blood sampling.
• Describe the contraindications for use of certain venous sites for IV access or phlebotomy (such as hemodialysis catheters, limb with neurovascular compromise, jugular vein with a neighboring ventriculo-peritoneal shunt, and others.)
• List the indications for arterial blood sampling.
• Describe the proper method for and common complications of obtaining venous and arterial blood samples.

Pediatric hospitalists should be able to:

• Perform a pre-procedural evaluation to determine risks and benefits of IV placement.
• Assess the need for and order appropriate pain and sedation medication and nonmedication interventions.
• Demonstrate the ability to obtain IV access on children of all ages via accessing appropriate personnel or safe performance of the procedure, according to local practice parameters.
• Obtain venous and arterial blood sampling (phlebotomy), with and without IV access, via accessing appropriate personnel or safe performance of the procedure, according to local practice parameters.
• Identify proper techniques for holding and calming patients before, during, and after access attempts and educate other healthcare providers in those techniques.
• Adhere to infection control practices.
• Utilize available modalities where available, such as vein-finding illuminators and ultrasound guidance, to achieve higher rates of procedural success.
• Demonstrate proficiency with intraosseous needle placement as evidenced by successful insertion of the IO needle in a simulated mock code situation.
• Identify barriers to efficient, effective IV access and engage subspecialists, including interventional radiology, anesthesiology, and surgery, to assist as appropriate.
• Identify common complications of IVs and blood sampling and respond with appropriate actions.
• Identify and initiate actions to limit unnecessary intravenous access or sampling by using strategies such as batching of lab tests, transition to oral medication, enteral rehydration, discouraging routine daily lab draws, and daily documentation of need for intravenous access.
• Obtain central venous access and PICCs when indicated via accessing appropriate consultants or safe performance of the procedure, according to local practice parameters.
• Demonstrate proficiency in addressing complications associated with peripheral and central lines (such as infiltrations, clots, displacements, and others) by prompt identification of the problem, initiation of indicated therapy, and consultation with appropriate subspecialists as indicated.

Pediatric hospitalists should be able to:

• Exemplify effective communication with patients and the family/caregivers regarding the indications for, and risks, benefits, and steps of the procedure.
• Role model and advocate for safety during procedures, by strict adherence to infection control practices and use of the “time-out for safety” verification process.
• Acknowledge the importance of revising the IV access plan as appropriate given patient and system limitations.
• Recognize the importance of limiting attempts at IV access in young children, with a need for an alternative plan when indicated.

In order to improve efficiency and quality within their organizations, pediatric hospitalists should:

• Lead, coordinate, or participate in the development and implementation of cost-effective, safe, evidence-based procedures and policies for IV access, adhering to national guidelines for infection control.
• Collaborate with hospital administration and clinical leaders to ensure adherence to modern procedural sedation and pain control guidelines, including limiting IV access attempts when an alternative plan is clinically feasible.
• Lead, coordinate, or participate in the development and implementation of a system for review of the efficacy, efficiency, and outcomes of intravenous access procedures.
• Lead, coordinate, or participate in the development and implementation of a system for review of family/caregiver and healthcare provider satisfaction related to venous access procedures.