Introduction

Feeding tubes are used in pediatric patients to deliver enteral nutrition, hydration, and medications. Common indications for tube feedings include the inability to meet metabolic demands through oral intake alone and oromotor dyscoordination with risk for aspiration. The need for gastric or transpyloric feeds, the anticipated duration of need, and preferences of patients and the family/caregivers are important factors in the selection of the type of feeding tube placed. Orogastric (OG), nasogastric (NG), and nasojejunal (NJ) tubes are commonly used for short-term needs, typically up to 12 weeks duration. Long-term options include gastric (G), gastrojejunal (GJ), and jejunal (J) tubes. Pediatric hospitalists often encounter children with or in need of feeding tubes and should understand the indications, limitations, and complications associated with their use.

Pediatric hospitalists should be able to:

• Describe basic gastrointestinal anatomy and physiology and how this relates to commonly used feeding tubes.
• Compare and contrast the indications, limitations, and complications of various types of feeding tubes, including OG, NG, NJ, G, GJ, and J tubes.
• Discuss the risks and benefits of short-term enteral feeding compared to intravenous fluid or parenteral nutrition use.
• Compare and contrast the risks and benefits of surgical, endoscopic, and percutaneous techniques for placement of feeding tubes.
• Describe the correct procedure to replace each type of feeding tube, including the associated potential complications.
• Review commonly encountered nonemergent complications of feeding tubes, such as leakage, local irritation, granulation tissue, cellulitis, dislodgement, and clogging.
• Describe potential emergent complications associated with enteral feeding tubes, such as accidental nasal tube placement into the lungs, tube migration, bowel obstruction, visceral puncture, peritonitis, and intussusception.
• List the indications, risks, benefits, and alternatives for surgical gastrostomy with Nissen fundoplication.
• Anticipate discharge needs for patients with feeding tubes, including replacement supplies, education/teaching for care providers, and contingency plans for tube issues, including dislodgment.
• Discuss the role of primary care providers, home health care, subspecialists, registered dieticians, and the family/caregivers in the home management of feeding tubes.

Pediatric hospitalists should be able to:

• Identify patients requiring alternative feeding modalities and prescribe appropriate short or long-term enteral tube placement, as determined clinically.
• Articulate the risks and benefits of combining Nissen fundoplication with G tube placement vs. GJ tube placement to patients and the family/caregivers.
• Prescribe enteral formula choice as well as feeding and advancing regimens (including bolus, continuous, and combination feeds), in collaboration with appropriate subspecialists and registered dieticians.
• Collaborate with subspecialists and registered dieticians to manage tube feeding regimes for patients with feeding intolerance.
• Collaborate with wound care specialists to preserve feeding tube site skin health.
• Monitor nutritional outcomes, such as linear growth and nutritional laboratory values, in children who receive tube feeding.
• Assess the necessity of existing feeding tubes in patients during each inpatient encounter, regardless of the reason for hospitalization.
• Initiate appropriate treatment for common complications associated with feeding tubes, in collaboration with appropriate subspecialists.
• Identify serious complications of tube feedings and prescribe appropriate evidence-based interventions, including ordering appropriate radiological studies and obtaining expeditious subspecialty consultation.
• Demonstrate basic proficiency in the interpretation of radiographic studies commonly performed to assess correct tube placement.
• Collaborate with occupational therapists and/or speech and language pathologists to determine appropriate timing for introduction and/or advancement of oral feeding regimes in children with feeding tubes.
• Educate patients and the family/caregivers about the use and care of feeding tubes, including replacement of dislodged tubes if appropriate, prior to discharge home.

Introduction

Feeding tubes are used in pediatric patients to deliver enteral nutrition, hydration, and medications. Common indications for tube feedings include the inability to meet metabolic demands through oral intake alone and oromotor dyscoordination with risk for aspiration. The need for gastric or transpyloric feeds, the anticipated duration of need, and preferences of patients and the family/caregivers are important factors in the selection of the type of feeding tube placed. Orogastric (OG), nasogastric (NG), and nasojejunal (NJ) tubes are commonly used for short-term needs, typically up to 12 weeks duration. Long-term options include gastric (G), gastrojejunal (GJ), and jejunal (J) tubes. Pediatric hospitalists often encounter children with or in need of feeding tubes and should understand the indications, limitations, and complications associated with their use.

Pediatric hospitalists should be able to:

• Describe basic gastrointestinal anatomy and physiology and how this relates to commonly used feeding tubes.
• Compare and contrast the indications, limitations, and complications of various types of feeding tubes, including OG, NG, NJ, G, GJ, and J tubes.
• Discuss the risks and benefits of short-term enteral feeding compared to intravenous fluid or parenteral nutrition use.
• Compare and contrast the risks and benefits of surgical, endoscopic, and percutaneous techniques for placement of feeding tubes.
• Describe the correct procedure to replace each type of feeding tube, including the associated potential complications.
• Review commonly encountered nonemergent complications of feeding tubes, such as leakage, local irritation, granulation tissue, cellulitis, dislodgement, and clogging.
• Describe potential emergent complications associated with enteral feeding tubes, such as accidental nasal tube placement into the lungs, tube migration, bowel obstruction, visceral puncture, peritonitis, and intussusception.
• List the indications, risks, benefits, and alternatives for surgical gastrostomy with Nissen fundoplication.
• Anticipate discharge needs for patients with feeding tubes, including replacement supplies, education/teaching for care providers, and contingency plans for tube issues, including dislodgment.
• Discuss the role of primary care providers, home health care, subspecialists, registered dieticians, and the family/caregivers in the home management of feeding tubes.

Pediatric hospitalists should be able to:

• Identify patients requiring alternative feeding modalities and prescribe appropriate short or long-term enteral tube placement, as determined clinically.
• Articulate the risks and benefits of combining Nissen fundoplication with G tube placement vs. GJ tube placement to patients and the family/caregivers.
• Prescribe enteral formula choice as well as feeding and advancing regimens (including bolus, continuous, and combination feeds), in collaboration with appropriate subspecialists and registered dieticians.
• Collaborate with subspecialists and registered dieticians to manage tube feeding regimes for patients with feeding intolerance.
• Collaborate with wound care specialists to preserve feeding tube site skin health.
• Monitor nutritional outcomes, such as linear growth and nutritional laboratory values, in children who receive tube feeding.
• Assess the necessity of existing feeding tubes in patients during each inpatient encounter, regardless of the reason for hospitalization.
• Initiate appropriate treatment for common complications associated with feeding tubes, in collaboration with appropriate subspecialists.
• Identify serious complications of tube feedings and prescribe appropriate evidence-based interventions, including ordering appropriate radiological studies and obtaining expeditious subspecialty consultation.
• Demonstrate basic proficiency in the interpretation of radiographic studies commonly performed to assess correct tube placement.
• Collaborate with occupational therapists and/or speech and language pathologists to determine appropriate timing for introduction and/or advancement of oral feeding regimes in children with feeding tubes.
• Educate patients and the family/caregivers about the use and care of feeding tubes, including replacement of dislodged tubes if appropriate, prior to discharge home.

Introduction

Feeding tubes are used in pediatric patients to deliver enteral nutrition, hydration, and medications. Common indications for tube feedings include the inability to meet metabolic demands through oral intake alone and oromotor dyscoordination with risk for aspiration. The need for gastric or transpyloric feeds, the anticipated duration of need, and preferences of patients and the family/caregivers are important factors in the selection of the type of feeding tube placed. Orogastric (OG), nasogastric (NG), and nasojejunal (NJ) tubes are commonly used for short-term needs, typically up to 12 weeks duration. Long-term options include gastric (G), gastrojejunal (GJ), and jejunal (J) tubes. Pediatric hospitalists often encounter children with or in need of feeding tubes and should understand the indications, limitations, and complications associated with their use.

Pediatric hospitalists should be able to:

• Describe basic gastrointestinal anatomy and physiology and how this relates to commonly used feeding tubes.
• Compare and contrast the indications, limitations, and complications of various types of feeding tubes, including OG, NG, NJ, G, GJ, and J tubes.
• Discuss the risks and benefits of short-term enteral feeding compared to intravenous fluid or parenteral nutrition use.
• Compare and contrast the risks and benefits of surgical, endoscopic, and percutaneous techniques for placement of feeding tubes.
• Describe the correct procedure to replace each type of feeding tube, including the associated potential complications.
• Review commonly encountered nonemergent complications of feeding tubes, such as leakage, local irritation, granulation tissue, cellulitis, dislodgement, and clogging.
• Describe potential emergent complications associated with enteral feeding tubes, such as accidental nasal tube placement into the lungs, tube migration, bowel obstruction, visceral puncture, peritonitis, and intussusception.
• List the indications, risks, benefits, and alternatives for surgical gastrostomy with Nissen fundoplication.
• Anticipate discharge needs for patients with feeding tubes, including replacement supplies, education/teaching for care providers, and contingency plans for tube issues, including dislodgment.
• Discuss the role of primary care providers, home health care, subspecialists, registered dieticians, and the family/caregivers in the home management of feeding tubes.

Pediatric hospitalists should be able to:

• Identify patients requiring alternative feeding modalities and prescribe appropriate short or long-term enteral tube placement, as determined clinically.
• Articulate the risks and benefits of combining Nissen fundoplication with G tube placement vs. GJ tube placement to patients and the family/caregivers.
• Prescribe enteral formula choice as well as feeding and advancing regimens (including bolus, continuous, and combination feeds), in collaboration with appropriate subspecialists and registered dieticians.
• Collaborate with subspecialists and registered dieticians to manage tube feeding regimes for patients with feeding intolerance.
• Collaborate with wound care specialists to preserve feeding tube site skin health.
• Monitor nutritional outcomes, such as linear growth and nutritional laboratory values, in children who receive tube feeding.
• Assess the necessity of existing feeding tubes in patients during each inpatient encounter, regardless of the reason for hospitalization.
• Initiate appropriate treatment for common complications associated with feeding tubes, in collaboration with appropriate subspecialists.
• Identify serious complications of tube feedings and prescribe appropriate evidence-based interventions, including ordering appropriate radiological studies and obtaining expeditious subspecialty consultation.
• Demonstrate basic proficiency in the interpretation of radiographic studies commonly performed to assess correct tube placement.
• Collaborate with occupational therapists and/or speech and language pathologists to determine appropriate timing for introduction and/or advancement of oral feeding regimes in children with feeding tubes.
• Educate patients and the family/caregivers about the use and care of feeding tubes, including replacement of dislodged tubes if appropriate, prior to discharge home.

Introduction

Electrocardiograms (ECGs) are often obtained in the pediatric inpatient setting to screen for and diagnose a wide range of cardiac diseases and conditions, including structural defects and arrhythmias. Pediatric hospitalists frequently consider cardiac diseases and conditions in their differential diagnosis and should be able to recognize these disorders, in order to provide initial and potentially life-saving treatment. Therefore, pediatric hospitalists must be skilled at obtaining and interpreting ECGs.

Pediatric hospitalists should be able to:

• Describe the normal electrical cardiac cycle and the corresponding waveforms on an ECG tracing.
• Give examples of common indications for obtaining an ECG, including elements from the past or current history, exam, treatments in use or anticipated, and others.
• Review the steps in performing an ECG, including lead placement and other technical aspects of the procedure.
• Summarize a systematic approach to the interpretation of pediatric ECGs, including evaluation of heart rate; rhythm; P, QRS, and T wave axis; and waveform durations and intervals.
• Compare and contrast the features of ECGs across the age spectrum.
• Describe the common ECG changes associated with specific electrolyte disturbances.
• List medications commonly associated with potentially serious arrhythmias.
• Summarize findings on the ECG indicative of disease-specific patterns, including obstructive sleep apnea, hypertension, idiopathic chamber hypertrophy, and ischemia.
• Review the differential diagnosis of specific arrhythmias and conduction disturbances, including arrhythmias of sinus, atrial, and ventricular origin, atrioventricular blocks, bundle branch blocks, wide and narrow complex tachycardias, atrial or ventricular fibrillation, long QT syndrome, and pacemaker rhythms.
• Describe the appropriate treatment for commonly encountered specific cardiac arrhythmias, including medications, electrical cardioversion, and defibrillation.
• List the ECG findings that should prompt consultation with a cardiologist, intensivist, pulmonologist, or others, including life-threatening or unstable cardiac arrhythmias.

Pediatric hospitalists should be able to:

• Obtain an ECG using the standard number and placement of leads, recording speed, and sensitivity.
• Determine the heart rate from the ECG, considering both the atrial and ventricular rates if different.
• Determine the PR and QT intervals, P and QRS durations, and the P, QRS, and T wave axes.
• Calculate the corrected QT interval (QTc) and correctly diagnose prolonged QTc.
• Identify regular versus irregular rhythms and determine if rhythms are sinus in origin.
• Correctly identify irregular rhythms that have evidence of underlying patterns (such as 2^nd degree AV block and others) or have irregularly irregular rhythms (such as atrial fibrillation and others).
• Evaluate for chamber hypertrophy and screen for ischemia using standard methodologies for ECG interpretation by age.
• Identify patterns that are pathognomonic for certain diagnoses (such as delta waves in Wolff-Parkinson-White syndrome and others).
• Correctly identify abnormal cardiac rhythms and respond with appropriate actions and interventions where indicated, including cardiac monitoring, medications, electrical cardioversion, and defibrillation.
• Order appropriate monitoring for patients with or at risk for cardiac instability and correctly interpret monitor data.
• Engage consultants (such as pediatric cardiologists, intensivists, and others) and initiate intra- or interfacility transfers of care efficiently and appropriately when indicated.

Pediatric hospitalists should be able to:

• Realize the responsibility for obtaining an ECG and provide an accurate interpretation, working collaboratively with pediatric cardiology for assistance as indicated.
• Appreciate the importance of collaboration with subspecialists, including cardiologists and intensivists, to initiate patient transfer when ECG findings and clinical picture suggest a condition requiring a higher level of care.
• Role model effective communication with patients, the family/caregiver, and other healthcare providers regarding the need to obtain an ECG, findings, and subsequent care plan.
• Recognize the importance of collaborating with the primary care provider and subspecialists to ensure coordinated longitudinal care for children with cardiac pathology.

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, evidence-based policies regarding indications for obtaining an ECG.
• Engage pediatric cardiologists, hospital staff and leadership to ensure timely, reliable, and accurate ECG interpretation, with an effective, closed-loop communication system for reporting results.
• Collaborate with hospital administration and community partners to develop and sustain referral networks between local facilities and tertiary referral centers for hospitalized patients requiring specialized pediatric cardiology services.
• Lead, coordinate, or participate in efforts directed at educating healthcare providers about risk factors for cardiac arrhythmia, early identification of abnormal rhythms, and implementation of appropriate resuscitative efforts.

Introduction

Electrocardiograms (ECGs) are often obtained in the pediatric inpatient setting to screen for and diagnose a wide range of cardiac diseases and conditions, including structural defects and arrhythmias. Pediatric hospitalists frequently consider cardiac diseases and conditions in their differential diagnosis and should be able to recognize these disorders, in order to provide initial and potentially life-saving treatment. Therefore, pediatric hospitalists must be skilled at obtaining and interpreting ECGs.

Pediatric hospitalists should be able to:

• Describe the normal electrical cardiac cycle and the corresponding waveforms on an ECG tracing.
• Give examples of common indications for obtaining an ECG, including elements from the past or current history, exam, treatments in use or anticipated, and others.
• Review the steps in performing an ECG, including lead placement and other technical aspects of the procedure.
• Summarize a systematic approach to the interpretation of pediatric ECGs, including evaluation of heart rate; rhythm; P, QRS, and T wave axis; and waveform durations and intervals.
• Compare and contrast the features of ECGs across the age spectrum.
• Describe the common ECG changes associated with specific electrolyte disturbances.
• List medications commonly associated with potentially serious arrhythmias.
• Summarize findings on the ECG indicative of disease-specific patterns, including obstructive sleep apnea, hypertension, idiopathic chamber hypertrophy, and ischemia.
• Review the differential diagnosis of specific arrhythmias and conduction disturbances, including arrhythmias of sinus, atrial, and ventricular origin, atrioventricular blocks, bundle branch blocks, wide and narrow complex tachycardias, atrial or ventricular fibrillation, long QT syndrome, and pacemaker rhythms.
• Describe the appropriate treatment for commonly encountered specific cardiac arrhythmias, including medications, electrical cardioversion, and defibrillation.
• List the ECG findings that should prompt consultation with a cardiologist, intensivist, pulmonologist, or others, including life-threatening or unstable cardiac arrhythmias.

Pediatric hospitalists should be able to:

• Obtain an ECG using the standard number and placement of leads, recording speed, and sensitivity.
• Determine the heart rate from the ECG, considering both the atrial and ventricular rates if different.
• Determine the PR and QT intervals, P and QRS durations, and the P, QRS, and T wave axes.
• Calculate the corrected QT interval (QTc) and correctly diagnose prolonged QTc.
• Identify regular versus irregular rhythms and determine if rhythms are sinus in origin.
• Correctly identify irregular rhythms that have evidence of underlying patterns (such as 2^nd degree AV block and others) or have irregularly irregular rhythms (such as atrial fibrillation and others).
• Evaluate for chamber hypertrophy and screen for ischemia using standard methodologies for ECG interpretation by age.
• Identify patterns that are pathognomonic for certain diagnoses (such as delta waves in Wolff-Parkinson-White syndrome and others).
• Correctly identify abnormal cardiac rhythms and respond with appropriate actions and interventions where indicated, including cardiac monitoring, medications, electrical cardioversion, and defibrillation.
• Order appropriate monitoring for patients with or at risk for cardiac instability and correctly interpret monitor data.
• Engage consultants (such as pediatric cardiologists, intensivists, and others) and initiate intra- or interfacility transfers of care efficiently and appropriately when indicated.

Pediatric hospitalists should be able to:

• Realize the responsibility for obtaining an ECG and provide an accurate interpretation, working collaboratively with pediatric cardiology for assistance as indicated.
• Appreciate the importance of collaboration with subspecialists, including cardiologists and intensivists, to initiate patient transfer when ECG findings and clinical picture suggest a condition requiring a higher level of care.
• Role model effective communication with patients, the family/caregiver, and other healthcare providers regarding the need to obtain an ECG, findings, and subsequent care plan.
• Recognize the importance of collaborating with the primary care provider and subspecialists to ensure coordinated longitudinal care for children with cardiac pathology.

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, evidence-based policies regarding indications for obtaining an ECG.
• Engage pediatric cardiologists, hospital staff and leadership to ensure timely, reliable, and accurate ECG interpretation, with an effective, closed-loop communication system for reporting results.
• Collaborate with hospital administration and community partners to develop and sustain referral networks between local facilities and tertiary referral centers for hospitalized patients requiring specialized pediatric cardiology services.
• Lead, coordinate, or participate in efforts directed at educating healthcare providers about risk factors for cardiac arrhythmia, early identification of abnormal rhythms, and implementation of appropriate resuscitative efforts.

Introduction

Electrocardiograms (ECGs) are often obtained in the pediatric inpatient setting to screen for and diagnose a wide range of cardiac diseases and conditions, including structural defects and arrhythmias. Pediatric hospitalists frequently consider cardiac diseases and conditions in their differential diagnosis and should be able to recognize these disorders, in order to provide initial and potentially life-saving treatment. Therefore, pediatric hospitalists must be skilled at obtaining and interpreting ECGs.

Pediatric hospitalists should be able to:

• Describe the normal electrical cardiac cycle and the corresponding waveforms on an ECG tracing.
• Give examples of common indications for obtaining an ECG, including elements from the past or current history, exam, treatments in use or anticipated, and others.
• Review the steps in performing an ECG, including lead placement and other technical aspects of the procedure.
• Summarize a systematic approach to the interpretation of pediatric ECGs, including evaluation of heart rate; rhythm; P, QRS, and T wave axis; and waveform durations and intervals.
• Compare and contrast the features of ECGs across the age spectrum.
• Describe the common ECG changes associated with specific electrolyte disturbances.
• List medications commonly associated with potentially serious arrhythmias.
• Summarize findings on the ECG indicative of disease-specific patterns, including obstructive sleep apnea, hypertension, idiopathic chamber hypertrophy, and ischemia.
• Review the differential diagnosis of specific arrhythmias and conduction disturbances, including arrhythmias of sinus, atrial, and ventricular origin, atrioventricular blocks, bundle branch blocks, wide and narrow complex tachycardias, atrial or ventricular fibrillation, long QT syndrome, and pacemaker rhythms.
• Describe the appropriate treatment for commonly encountered specific cardiac arrhythmias, including medications, electrical cardioversion, and defibrillation.
• List the ECG findings that should prompt consultation with a cardiologist, intensivist, pulmonologist, or others, including life-threatening or unstable cardiac arrhythmias.

Pediatric hospitalists should be able to:

• Obtain an ECG using the standard number and placement of leads, recording speed, and sensitivity.
• Determine the heart rate from the ECG, considering both the atrial and ventricular rates if different.
• Determine the PR and QT intervals, P and QRS durations, and the P, QRS, and T wave axes.
• Calculate the corrected QT interval (QTc) and correctly diagnose prolonged QTc.
• Identify regular versus irregular rhythms and determine if rhythms are sinus in origin.
• Correctly identify irregular rhythms that have evidence of underlying patterns (such as 2^nd degree AV block and others) or have irregularly irregular rhythms (such as atrial fibrillation and others).
• Evaluate for chamber hypertrophy and screen for ischemia using standard methodologies for ECG interpretation by age.
• Identify patterns that are pathognomonic for certain diagnoses (such as delta waves in Wolff-Parkinson-White syndrome and others).
• Correctly identify abnormal cardiac rhythms and respond with appropriate actions and interventions where indicated, including cardiac monitoring, medications, electrical cardioversion, and defibrillation.
• Order appropriate monitoring for patients with or at risk for cardiac instability and correctly interpret monitor data.
• Engage consultants (such as pediatric cardiologists, intensivists, and others) and initiate intra- or interfacility transfers of care efficiently and appropriately when indicated.

Pediatric hospitalists should be able to:

• Realize the responsibility for obtaining an ECG and provide an accurate interpretation, working collaboratively with pediatric cardiology for assistance as indicated.
• Appreciate the importance of collaboration with subspecialists, including cardiologists and intensivists, to initiate patient transfer when ECG findings and clinical picture suggest a condition requiring a higher level of care.
• Role model effective communication with patients, the family/caregiver, and other healthcare providers regarding the need to obtain an ECG, findings, and subsequent care plan.
• Recognize the importance of collaborating with the primary care provider and subspecialists to ensure coordinated longitudinal care for children with cardiac pathology.

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, evidence-based policies regarding indications for obtaining an ECG.
• Engage pediatric cardiologists, hospital staff and leadership to ensure timely, reliable, and accurate ECG interpretation, with an effective, closed-loop communication system for reporting results.
• Collaborate with hospital administration and community partners to develop and sustain referral networks between local facilities and tertiary referral centers for hospitalized patients requiring specialized pediatric cardiology services.
• Lead, coordinate, or participate in efforts directed at educating healthcare providers about risk factors for cardiac arrhythmia, early identification of abnormal rhythms, and implementation of appropriate resuscitative efforts.

Introduction

Radiographic studies have become fully integrated into the daily practice of Pediatric Hospital Medicine, as the interpretation of a given image often plays a pivotal role in the management of a hospitalized child. With the explosion of imaging technology in the past three decades, clinicians are now faced with a myriad of possible studies from which to choose. The choices vary by setting, as availability and expertise with different imaging modalities can differ by institution and practice setting. More recently, there has been a greater appreciation of the potential impact of ionizing radiation when applied to young children. Judicious use of radiographic studies requires a collaborative, team-based approach, working closely with radiology and subspecialty colleagues to best utilize these powerful clinical tools. Knowledge of the studies locally available, selection of the optimal imaging modality, and interpretation of the most common radiographic studies remain critically important for pediatric hospitalists in any setting.

Pediatric hospitalists should be able to:

• Describe relevant human anatomy and relate this to interpretation of common plain radiographs of areas such as the chest, abdomen, airway, and long bones.
• Describe the indications and limitations of different radiographic modalities, including plain radiography, fluoroscopy, ultrasound, computed tomography, magnetic resonance imaging, and nuclear medicine.
• List the risks of ionizing radiation in children and review the concept of ALARA (as low as reasonably achievable) in limiting radiation exposure.
• Review the indications for, and benefits and risks of, oral and intravenous contrast.
• Review the indications for anxiolytics, sedation, and anesthesia relevant to age, developmental stage, and the procedure being performed.
• List the appropriate imaging study for common clinical presentations, such as acute respiratory distress, altered mental status, stridor, abdominal pain, and others.
• Compare and contrast the utility, risks, and costs of different imaging modalities for presentations of complicated pneumonia and acute abdominal pain.
• Discuss the impact of practice setting on the availability of pediatric radiological services.

Pediatric hospitalists should be able to:

• Choose the optimal study to answer a specific clinical question in a safe, cost-effective manner.
• Order radiologic studies, noting indications for the study, the clinical question to answer, sedation/anesthesia need, and other relevant information within the order.
• Perform initial interpretation of the most common radiographic studies in daily practice, such as plain radiographs of the chest and abdomen for children 0-18 years of age.
• Interpret radiographic studies to diagnose time-sensitive conditions, such as a pneumothorax, prior to review and interpretation by a radiologist.
• Integrate the results of radiographic studies into ongoing clinical care plans.
• Engage the radiologist and subspecialists as consultants in imaging decisions.
• Communicate effectively with nurses, trainees, radiologists, and sedation experts, to ensure safe and effective performance of radiographic studies.
• Communicate effectively with patients and the family/caregivers in order to address concerns regarding radiation exposure and risk.
• Communicate effectively with patient and the family/caregivers in order to provide basic teaching and understanding of results of radiographic images and the impact on the overall care plan.

Pediatric hospitalists should be able to:

• Recognize the radiologist as a consultant with whom to collaborate in decision-making.
• Appreciate the importance of collaborating with hospital staff, radiologists, and sedation and anesthesia experts, to ensure coordinated timing, planning, and performance of radiologic studies.
• Realize the value of effective communication with patients and the family/caregivers regarding the indications for, risks, benefits, alternatives, and steps involved in the radiologic procedure.
• Recognize the importance of obtaining results of all studies and reviewing images in a timely manner.

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 standards for radiology services for children, ensuring that standards and protocols for minimizing ionizing radiation to children are in place.
• Lead, coordinate, or participate in development and implementation of a system to review the accuracy of readings for pediatric patients.
• Work with hospital administration to ensure that clinicians have appropriate and necessary access to key imaging modalities to practice at the standard of care.
• Collaborate with hospital administration and community partners to develop and sustain referral networks between local facilities and tertiary referral centers, so as to allow review of pediatric images between centers to benefit patient care.
• Work with hospital administration, subspecialists, and others to review acquisition of new technologies which are cost effective and positively impact patient care.

Introduction

Radiographic studies have become fully integrated into the daily practice of Pediatric Hospital Medicine, as the interpretation of a given image often plays a pivotal role in the management of a hospitalized child. With the explosion of imaging technology in the past three decades, clinicians are now faced with a myriad of possible studies from which to choose. The choices vary by setting, as availability and expertise with different imaging modalities can differ by institution and practice setting. More recently, there has been a greater appreciation of the potential impact of ionizing radiation when applied to young children. Judicious use of radiographic studies requires a collaborative, team-based approach, working closely with radiology and subspecialty colleagues to best utilize these powerful clinical tools. Knowledge of the studies locally available, selection of the optimal imaging modality, and interpretation of the most common radiographic studies remain critically important for pediatric hospitalists in any setting.

Pediatric hospitalists should be able to:

• Describe relevant human anatomy and relate this to interpretation of common plain radiographs of areas such as the chest, abdomen, airway, and long bones.
• Describe the indications and limitations of different radiographic modalities, including plain radiography, fluoroscopy, ultrasound, computed tomography, magnetic resonance imaging, and nuclear medicine.
• List the risks of ionizing radiation in children and review the concept of ALARA (as low as reasonably achievable) in limiting radiation exposure.
• Review the indications for, and benefits and risks of, oral and intravenous contrast.
• Review the indications for anxiolytics, sedation, and anesthesia relevant to age, developmental stage, and the procedure being performed.
• List the appropriate imaging study for common clinical presentations, such as acute respiratory distress, altered mental status, stridor, abdominal pain, and others.
• Compare and contrast the utility, risks, and costs of different imaging modalities for presentations of complicated pneumonia and acute abdominal pain.
• Discuss the impact of practice setting on the availability of pediatric radiological services.

Pediatric hospitalists should be able to:

• Choose the optimal study to answer a specific clinical question in a safe, cost-effective manner.
• Order radiologic studies, noting indications for the study, the clinical question to answer, sedation/anesthesia need, and other relevant information within the order.
• Perform initial interpretation of the most common radiographic studies in daily practice, such as plain radiographs of the chest and abdomen for children 0-18 years of age.
• Interpret radiographic studies to diagnose time-sensitive conditions, such as a pneumothorax, prior to review and interpretation by a radiologist.
• Integrate the results of radiographic studies into ongoing clinical care plans.
• Engage the radiologist and subspecialists as consultants in imaging decisions.
• Communicate effectively with nurses, trainees, radiologists, and sedation experts, to ensure safe and effective performance of radiographic studies.
• Communicate effectively with patients and the family/caregivers in order to address concerns regarding radiation exposure and risk.
• Communicate effectively with patient and the family/caregivers in order to provide basic teaching and understanding of results of radiographic images and the impact on the overall care plan.

Pediatric hospitalists should be able to:

• Recognize the radiologist as a consultant with whom to collaborate in decision-making.
• Appreciate the importance of collaborating with hospital staff, radiologists, and sedation and anesthesia experts, to ensure coordinated timing, planning, and performance of radiologic studies.
• Realize the value of effective communication with patients and the family/caregivers regarding the indications for, risks, benefits, alternatives, and steps involved in the radiologic procedure.
• Recognize the importance of obtaining results of all studies and reviewing images in a timely manner.

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 standards for radiology services for children, ensuring that standards and protocols for minimizing ionizing radiation to children are in place.
• Lead, coordinate, or participate in development and implementation of a system to review the accuracy of readings for pediatric patients.
• Work with hospital administration to ensure that clinicians have appropriate and necessary access to key imaging modalities to practice at the standard of care.
• Collaborate with hospital administration and community partners to develop and sustain referral networks between local facilities and tertiary referral centers, so as to allow review of pediatric images between centers to benefit patient care.
• Work with hospital administration, subspecialists, and others to review acquisition of new technologies which are cost effective and positively impact patient care.

Introduction

Radiographic studies have become fully integrated into the daily practice of Pediatric Hospital Medicine, as the interpretation of a given image often plays a pivotal role in the management of a hospitalized child. With the explosion of imaging technology in the past three decades, clinicians are now faced with a myriad of possible studies from which to choose. The choices vary by setting, as availability and expertise with different imaging modalities can differ by institution and practice setting. More recently, there has been a greater appreciation of the potential impact of ionizing radiation when applied to young children. Judicious use of radiographic studies requires a collaborative, team-based approach, working closely with radiology and subspecialty colleagues to best utilize these powerful clinical tools. Knowledge of the studies locally available, selection of the optimal imaging modality, and interpretation of the most common radiographic studies remain critically important for pediatric hospitalists in any setting.

Pediatric hospitalists should be able to:

• Describe relevant human anatomy and relate this to interpretation of common plain radiographs of areas such as the chest, abdomen, airway, and long bones.
• Describe the indications and limitations of different radiographic modalities, including plain radiography, fluoroscopy, ultrasound, computed tomography, magnetic resonance imaging, and nuclear medicine.
• List the risks of ionizing radiation in children and review the concept of ALARA (as low as reasonably achievable) in limiting radiation exposure.
• Review the indications for, and benefits and risks of, oral and intravenous contrast.
• Review the indications for anxiolytics, sedation, and anesthesia relevant to age, developmental stage, and the procedure being performed.
• List the appropriate imaging study for common clinical presentations, such as acute respiratory distress, altered mental status, stridor, abdominal pain, and others.
• Compare and contrast the utility, risks, and costs of different imaging modalities for presentations of complicated pneumonia and acute abdominal pain.
• Discuss the impact of practice setting on the availability of pediatric radiological services.

Pediatric hospitalists should be able to:

• Choose the optimal study to answer a specific clinical question in a safe, cost-effective manner.
• Order radiologic studies, noting indications for the study, the clinical question to answer, sedation/anesthesia need, and other relevant information within the order.
• Perform initial interpretation of the most common radiographic studies in daily practice, such as plain radiographs of the chest and abdomen for children 0-18 years of age.
• Interpret radiographic studies to diagnose time-sensitive conditions, such as a pneumothorax, prior to review and interpretation by a radiologist.
• Integrate the results of radiographic studies into ongoing clinical care plans.
• Engage the radiologist and subspecialists as consultants in imaging decisions.
• Communicate effectively with nurses, trainees, radiologists, and sedation experts, to ensure safe and effective performance of radiographic studies.
• Communicate effectively with patients and the family/caregivers in order to address concerns regarding radiation exposure and risk.
• Communicate effectively with patient and the family/caregivers in order to provide basic teaching and understanding of results of radiographic images and the impact on the overall care plan.

Pediatric hospitalists should be able to:

• Recognize the radiologist as a consultant with whom to collaborate in decision-making.
• Appreciate the importance of collaborating with hospital staff, radiologists, and sedation and anesthesia experts, to ensure coordinated timing, planning, and performance of radiologic studies.
• Realize the value of effective communication with patients and the family/caregivers regarding the indications for, risks, benefits, alternatives, and steps involved in the radiologic procedure.
• Recognize the importance of obtaining results of all studies and reviewing images in a timely manner.

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 standards for radiology services for children, ensuring that standards and protocols for minimizing ionizing radiation to children are in place.
• Lead, coordinate, or participate in development and implementation of a system to review the accuracy of readings for pediatric patients.
• Work with hospital administration to ensure that clinicians have appropriate and necessary access to key imaging modalities to practice at the standard of care.
• Collaborate with hospital administration and community partners to develop and sustain referral networks between local facilities and tertiary referral centers, so as to allow review of pediatric images between centers to benefit patient care.
• Work with hospital administration, subspecialists, and others to review acquisition of new technologies which are cost effective and positively impact patient care.

Introduction

The ability to communicate effectively is a core skill for all physicians. It is of particular importance for pediatric hospitalists, who may have more limited longitudinal relationships with patients. This skill is pivotal to clinical practice, as it helps to establish rapport and a therapeutic alliance with patients and the family/caregivers. Communication is delivered both verbally and nonverbally, and can be learned and improved with practice, as with any other technical or clinical proficiency. Pediatric hospitalists must demonstrate effective communication in a variety of settings, including direct patient care, interactions with colleagues, and trainee education. The most critical setting for effective communication is at the bedside, where a pediatric hospitalist must communicate key information clearly and efficiently to patients, the family/caregivers, and to the entire healthcare team.

Pediatric hospitalists should be able to:

• Define the components of effective expressive and receptive communication, such as introduction of team members and their roles, avoiding medical jargon, using calm tone, appropriate word choice and body language, and allowing adequate time for patient and family input.
• Identify personal values, biases, and relationships that may influence communication.
• Discuss the benefits of including the family/caregivers and others who are important to the patient in daily decision-making and long-term plan development.
• Describe the importance of listening carefully, followed by effective use of information obtained to form conclusions and guide interventions.
• List examples of common nonlistening behaviors to avoid, such as allowing distractions, asking unrelated questions, jumping to conclusions, interrupting the speaker, and failing to notice the speaker’s nonverbal language.
• Understand the inherent vulnerability patients and the family/caregivers may feel when hospitalized and how this can affect bedside communication with the care team.
• Describe the importance of considering the cultural factors and spiritual beliefs of patients and the family/caregivers when establishing a therapeutic relationship.
• Explain how vulnerabilities, life situations, limitations in activities of daily living, education, language, and other factors should each be considered and addressed when communicating with patients and the family/caregivers.
• Discuss methods to achieve a more favorable interchange when faced with agitated communicators, such as asking for behavior change, paraphrasing to diffuse emotion, pausing the interaction until all parties are able to participate productively, and others.
• Describe practices essential for effective communication of difficult information, including sitting down, expressing empathy, giving patients and the family/caregivers time to ask questions, maintaining a calm demeanor, and choosing a quiet, private location for the discussion.
• Describe components of effective written communication, including timing of clinical documentation, legibility, grammar, accuracy, disagreements in approaches to care, and documentation of clinical changes.
• Explain why effective communication is central to patient safety during handoffs and list evidence-based handoff tools for use within hospitalist groups and with other healthcare providers.

Pediatric hospitalists should be able to:

• Demonstrate command of a comprehensive array of expressive and receptive communication skills.
• Develop and implement effective plan for daily communication that is family-centered and models best practices in communication, such as sitting down, avoiding jargon, and addressing key patient/family concerns.
• Engage patients and the family/caregivers in shared decision-making regarding the child’s plan of care.
• Coordinate discussions with all clinical care team members (such as nurses, consultants, and others) to ensure a single clear message is given to patients, the family, and all caregivers for the child.
• Demonstrate closed-loop communication to improve patient safety and decrease communication errors.
• Participate in conflict resolution, both within the health care team and between team members and the family/caregivers when indicated.
• Identify when the use of interpreters for patients and the family/caregivers with limited English language proficiency is necessary and effectively integrate interpreters into the communication plan.
• Lead and facilitate a multidisciplinary care conference when applicable.
• Record concise, complete written documents that accurately and succinctly relay key patient information, while meeting expectations of external reviewing agencies and malpractice carriers.
• Develop clear and concise discharge instructions for patients and the family/caregivers.
• Communicate in a timely manner with a child’s primary care provider, incorporating information on the admission reason, hospital course, discharge diagnosis, discharge plan, and follow-up needs and recommendations.

Pediatric hospitalists should be able to:

• Acknowledge the importance of respecting the skills and contributions of all clinical and nonclinical providers involved in the care of patients.
• Realize the responsibility for promoting equitable interactions with patients and the family/caregivers, free from bias related to background, age, language, education level, race, or ethnicity.
• Exemplify professionalism in all communication.
• Seek opportunities to enhance communication skills.

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

• Collaborate with hospital administrators to improve medical record documentation systems by technical means.
• Lead, support, or assist in the development of hospital and system-wide educational programs to enhance communication skills and decrease communication-related errors.
• Work with hospital administration to establish or evaluate existing patient and family experience metrics to ultimately improve communication at the bedside.
• Lead, coordinate, or participate in activities to support effective communication methods for patients and the family/caregivers with limited English language proficiency.

Introduction

The ability to communicate effectively is a core skill for all physicians. It is of particular importance for pediatric hospitalists, who may have more limited longitudinal relationships with patients. This skill is pivotal to clinical practice, as it helps to establish rapport and a therapeutic alliance with patients and the family/caregivers. Communication is delivered both verbally and nonverbally, and can be learned and improved with practice, as with any other technical or clinical proficiency. Pediatric hospitalists must demonstrate effective communication in a variety of settings, including direct patient care, interactions with colleagues, and trainee education. The most critical setting for effective communication is at the bedside, where a pediatric hospitalist must communicate key information clearly and efficiently to patients, the family/caregivers, and to the entire healthcare team.

Pediatric hospitalists should be able to:

• Define the components of effective expressive and receptive communication, such as introduction of team members and their roles, avoiding medical jargon, using calm tone, appropriate word choice and body language, and allowing adequate time for patient and family input.
• Identify personal values, biases, and relationships that may influence communication.
• Discuss the benefits of including the family/caregivers and others who are important to the patient in daily decision-making and long-term plan development.
• Describe the importance of listening carefully, followed by effective use of information obtained to form conclusions and guide interventions.
• List examples of common nonlistening behaviors to avoid, such as allowing distractions, asking unrelated questions, jumping to conclusions, interrupting the speaker, and failing to notice the speaker’s nonverbal language.
• Understand the inherent vulnerability patients and the family/caregivers may feel when hospitalized and how this can affect bedside communication with the care team.
• Describe the importance of considering the cultural factors and spiritual beliefs of patients and the family/caregivers when establishing a therapeutic relationship.
• Explain how vulnerabilities, life situations, limitations in activities of daily living, education, language, and other factors should each be considered and addressed when communicating with patients and the family/caregivers.
• Discuss methods to achieve a more favorable interchange when faced with agitated communicators, such as asking for behavior change, paraphrasing to diffuse emotion, pausing the interaction until all parties are able to participate productively, and others.
• Describe practices essential for effective communication of difficult information, including sitting down, expressing empathy, giving patients and the family/caregivers time to ask questions, maintaining a calm demeanor, and choosing a quiet, private location for the discussion.
• Describe components of effective written communication, including timing of clinical documentation, legibility, grammar, accuracy, disagreements in approaches to care, and documentation of clinical changes.
• Explain why effective communication is central to patient safety during handoffs and list evidence-based handoff tools for use within hospitalist groups and with other healthcare providers.

Pediatric hospitalists should be able to:

• Demonstrate command of a comprehensive array of expressive and receptive communication skills.
• Develop and implement effective plan for daily communication that is family-centered and models best practices in communication, such as sitting down, avoiding jargon, and addressing key patient/family concerns.
• Engage patients and the family/caregivers in shared decision-making regarding the child’s plan of care.
• Coordinate discussions with all clinical care team members (such as nurses, consultants, and others) to ensure a single clear message is given to patients, the family, and all caregivers for the child.
• Demonstrate closed-loop communication to improve patient safety and decrease communication errors.
• Participate in conflict resolution, both within the health care team and between team members and the family/caregivers when indicated.
• Identify when the use of interpreters for patients and the family/caregivers with limited English language proficiency is necessary and effectively integrate interpreters into the communication plan.
• Lead and facilitate a multidisciplinary care conference when applicable.
• Record concise, complete written documents that accurately and succinctly relay key patient information, while meeting expectations of external reviewing agencies and malpractice carriers.
• Develop clear and concise discharge instructions for patients and the family/caregivers.
• Communicate in a timely manner with a child’s primary care provider, incorporating information on the admission reason, hospital course, discharge diagnosis, discharge plan, and follow-up needs and recommendations.

Pediatric hospitalists should be able to:

• Acknowledge the importance of respecting the skills and contributions of all clinical and nonclinical providers involved in the care of patients.
• Realize the responsibility for promoting equitable interactions with patients and the family/caregivers, free from bias related to background, age, language, education level, race, or ethnicity.
• Exemplify professionalism in all communication.
• Seek opportunities to enhance communication skills.

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

• Collaborate with hospital administrators to improve medical record documentation systems by technical means.
• Lead, support, or assist in the development of hospital and system-wide educational programs to enhance communication skills and decrease communication-related errors.
• Work with hospital administration to establish or evaluate existing patient and family experience metrics to ultimately improve communication at the bedside.
• Lead, coordinate, or participate in activities to support effective communication methods for patients and the family/caregivers with limited English language proficiency.

Introduction

The ability to communicate effectively is a core skill for all physicians. It is of particular importance for pediatric hospitalists, who may have more limited longitudinal relationships with patients. This skill is pivotal to clinical practice, as it helps to establish rapport and a therapeutic alliance with patients and the family/caregivers. Communication is delivered both verbally and nonverbally, and can be learned and improved with practice, as with any other technical or clinical proficiency. Pediatric hospitalists must demonstrate effective communication in a variety of settings, including direct patient care, interactions with colleagues, and trainee education. The most critical setting for effective communication is at the bedside, where a pediatric hospitalist must communicate key information clearly and efficiently to patients, the family/caregivers, and to the entire healthcare team.

Pediatric hospitalists should be able to:

• Define the components of effective expressive and receptive communication, such as introduction of team members and their roles, avoiding medical jargon, using calm tone, appropriate word choice and body language, and allowing adequate time for patient and family input.
• Identify personal values, biases, and relationships that may influence communication.
• Discuss the benefits of including the family/caregivers and others who are important to the patient in daily decision-making and long-term plan development.
• Describe the importance of listening carefully, followed by effective use of information obtained to form conclusions and guide interventions.
• List examples of common nonlistening behaviors to avoid, such as allowing distractions, asking unrelated questions, jumping to conclusions, interrupting the speaker, and failing to notice the speaker’s nonverbal language.
• Understand the inherent vulnerability patients and the family/caregivers may feel when hospitalized and how this can affect bedside communication with the care team.
• Describe the importance of considering the cultural factors and spiritual beliefs of patients and the family/caregivers when establishing a therapeutic relationship.
• Explain how vulnerabilities, life situations, limitations in activities of daily living, education, language, and other factors should each be considered and addressed when communicating with patients and the family/caregivers.
• Discuss methods to achieve a more favorable interchange when faced with agitated communicators, such as asking for behavior change, paraphrasing to diffuse emotion, pausing the interaction until all parties are able to participate productively, and others.
• Describe practices essential for effective communication of difficult information, including sitting down, expressing empathy, giving patients and the family/caregivers time to ask questions, maintaining a calm demeanor, and choosing a quiet, private location for the discussion.
• Describe components of effective written communication, including timing of clinical documentation, legibility, grammar, accuracy, disagreements in approaches to care, and documentation of clinical changes.
• Explain why effective communication is central to patient safety during handoffs and list evidence-based handoff tools for use within hospitalist groups and with other healthcare providers.

Pediatric hospitalists should be able to:

• Demonstrate command of a comprehensive array of expressive and receptive communication skills.
• Develop and implement effective plan for daily communication that is family-centered and models best practices in communication, such as sitting down, avoiding jargon, and addressing key patient/family concerns.
• Engage patients and the family/caregivers in shared decision-making regarding the child’s plan of care.
• Coordinate discussions with all clinical care team members (such as nurses, consultants, and others) to ensure a single clear message is given to patients, the family, and all caregivers for the child.
• Demonstrate closed-loop communication to improve patient safety and decrease communication errors.
• Participate in conflict resolution, both within the health care team and between team members and the family/caregivers when indicated.
• Identify when the use of interpreters for patients and the family/caregivers with limited English language proficiency is necessary and effectively integrate interpreters into the communication plan.
• Lead and facilitate a multidisciplinary care conference when applicable.
• Record concise, complete written documents that accurately and succinctly relay key patient information, while meeting expectations of external reviewing agencies and malpractice carriers.
• Develop clear and concise discharge instructions for patients and the family/caregivers.
• Communicate in a timely manner with a child’s primary care provider, incorporating information on the admission reason, hospital course, discharge diagnosis, discharge plan, and follow-up needs and recommendations.

Pediatric hospitalists should be able to:

• Acknowledge the importance of respecting the skills and contributions of all clinical and nonclinical providers involved in the care of patients.
• Realize the responsibility for promoting equitable interactions with patients and the family/caregivers, free from bias related to background, age, language, education level, race, or ethnicity.
• Exemplify professionalism in all communication.
• Seek opportunities to enhance communication skills.

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

• Collaborate with hospital administrators to improve medical record documentation systems by technical means.
• Lead, support, or assist in the development of hospital and system-wide educational programs to enhance communication skills and decrease communication-related errors.
• Work with hospital administration to establish or evaluate existing patient and family experience metrics to ultimately improve communication at the bedside.
• Lead, coordinate, or participate in activities to support effective communication methods for patients and the family/caregivers with limited English language proficiency.

Introduction

Bladder catheterization is a commonly performed procedure, typically used to collect a sterile urine sample for analysis and culture when urinary tract infection (UTI) is suspected. Bladder catheterization is also used to relieve urinary retention or obstruction, particularly in cases of anatomic abnormalities or neurogenic bladder, or to monitor urine output and overall fluid status. Pediatric hospitalists frequently encounter patients requiring bladder catheterization, and in many practice settings, may need to be adept at performing this procedure in infants, children, and adolescents. While not all pediatric hospitalists will regularly perform bladder catheterization, all will be required to interpret urinalysis (UA) in routine practice. A UA is most commonly used to diagnose UTI but can also be used to detect a wide range of pediatric conditions, including primary renal disease, trauma, diabetes, and metabolic disease. The ability to effectively interpret a urinalysis in the inpatient setting remains a core skill for the pediatric hospitalist.

Pediatric hospitalists should be able to:

• Review the basic anatomy of the male and female genitourinary tract.
• Discuss the indications and contraindications for bladder catheterization.
• Describe how the method used to collect a urine specimen can affect interpretation of urine culture results.
• Explain why bladder catheterization is the preferred method of collection in infants and children who cannot reliably produce a voided specimen or in whom a sterile sample is needed.
• Compare and contrast the implications of using different methods to collect a urine specimen, including the varied ability to correctly interpret the UA and culture.
• Describe the steps in performing bladder catheterization for both male and female patients, attending to aspects such as patient identification, sterile technique, patient positioning, equipment needs, and specimen handling.
• Describe the risks and complications associated with bladder catheterization, including localized trauma, creation of a false passage, and potential stricture formation.
• Discuss the indications for analgesia, sedation, or anxiolysis and the medications that may be used for each.
• Describe the indications and risks of indwelling bladder catheters and the criteria for removal.
• Describe best practices and care bundles that can minimize the risk of catheter associated urinary tract infections (CAUTIs).
• Review the indications for consultation with a urologist for bladder catheterization, including known genitourinary tract abnormality, recent genitourinary surgery, or urethral trauma.
• Define a UTI in terms of minimum bacterial colony counts needed with different methods of obtaining the sample, such as catheterization, clean catch, and clean bag.
• Discuss the importance of appropriate specimen handling and the potential effect on culture results.
• Discuss the different components of a urinalysis, including specific gravity, white and red blood cell counts, protein, casts, and glucose, including how each can be used to detect and manage different pediatric conditions.
• Compare and contrast the sensitivity, specificity, and positive or negative predictive value of the leukocyte esterase and nitrite components of a UA in the diagnosis of UTI.

Pediatric hospitalists should be able to:

• Perform a pre-procedural evaluation to determine risks and benefits of bladder catheterization.
• Demonstrate proficiency in performance of bladder catheterization on infants, children, and adolescents, when required according to local practice.
• Identify the level of pain and anxiety provoked by the procedure and provide appropriate pharmacologic or nonpharmacologic interventions when indicated.
• Employ proper techniques for holding and calming patients before, during, and after bladder catheterization and educate healthcare providers in these practices when indicated.
• Consistently adhere to infection control practices.
• Identify complications and respond with appropriate actions.
• Distinguish the need for and efficiently access appropriate consultants and support services for assistance with analgesia, sedation, anxiolysis, and performance of a bladder catheterization.
• Diagnose pediatric conditions, such as UTI, nephrotic syndrome, glomerulonephritis, diabetes mellitus, and others, through effective interpretation of a UA.

Pediatric hospitalists should be able to:

• Realize the importance of obtaining a sterile urine specimen to correctly diagnose urinary tract infection.
• Realize the importance of effective communication with patients and the family/caregivers regarding the indications for, risks, benefits, and steps of bladder catheterization.
• Appreciate the need for collaboration with nurses, learners and other healthcare providers, to promote the use of evidence-based practices in maintenance of urinary catheters to decrease risk of CAUTIs in the inpatient setting.
• Exemplify appropriate adherence to and advocate for strict 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 bladder catheterization in children.
• Lead, coordinate, or participate in the development and implementation of educational initiatives designed to teach the proper technique for bladder catheterization as well as safe catheter maintenance when prolonged catheterization is required.

Introduction

Bladder catheterization is a commonly performed procedure, typically used to collect a sterile urine sample for analysis and culture when urinary tract infection (UTI) is suspected. Bladder catheterization is also used to relieve urinary retention or obstruction, particularly in cases of anatomic abnormalities or neurogenic bladder, or to monitor urine output and overall fluid status. Pediatric hospitalists frequently encounter patients requiring bladder catheterization, and in many practice settings, may need to be adept at performing this procedure in infants, children, and adolescents. While not all pediatric hospitalists will regularly perform bladder catheterization, all will be required to interpret urinalysis (UA) in routine practice. A UA is most commonly used to diagnose UTI but can also be used to detect a wide range of pediatric conditions, including primary renal disease, trauma, diabetes, and metabolic disease. The ability to effectively interpret a urinalysis in the inpatient setting remains a core skill for the pediatric hospitalist.

Pediatric hospitalists should be able to:

• Review the basic anatomy of the male and female genitourinary tract.
• Discuss the indications and contraindications for bladder catheterization.
• Describe how the method used to collect a urine specimen can affect interpretation of urine culture results.
• Explain why bladder catheterization is the preferred method of collection in infants and children who cannot reliably produce a voided specimen or in whom a sterile sample is needed.
• Compare and contrast the implications of using different methods to collect a urine specimen, including the varied ability to correctly interpret the UA and culture.
• Describe the steps in performing bladder catheterization for both male and female patients, attending to aspects such as patient identification, sterile technique, patient positioning, equipment needs, and specimen handling.
• Describe the risks and complications associated with bladder catheterization, including localized trauma, creation of a false passage, and potential stricture formation.
• Discuss the indications for analgesia, sedation, or anxiolysis and the medications that may be used for each.
• Describe the indications and risks of indwelling bladder catheters and the criteria for removal.
• Describe best practices and care bundles that can minimize the risk of catheter associated urinary tract infections (CAUTIs).
• Review the indications for consultation with a urologist for bladder catheterization, including known genitourinary tract abnormality, recent genitourinary surgery, or urethral trauma.
• Define a UTI in terms of minimum bacterial colony counts needed with different methods of obtaining the sample, such as catheterization, clean catch, and clean bag.
• Discuss the importance of appropriate specimen handling and the potential effect on culture results.
• Discuss the different components of a urinalysis, including specific gravity, white and red blood cell counts, protein, casts, and glucose, including how each can be used to detect and manage different pediatric conditions.
• Compare and contrast the sensitivity, specificity, and positive or negative predictive value of the leukocyte esterase and nitrite components of a UA in the diagnosis of UTI.

Pediatric hospitalists should be able to:

• Perform a pre-procedural evaluation to determine risks and benefits of bladder catheterization.
• Demonstrate proficiency in performance of bladder catheterization on infants, children, and adolescents, when required according to local practice.
• Identify the level of pain and anxiety provoked by the procedure and provide appropriate pharmacologic or nonpharmacologic interventions when indicated.
• Employ proper techniques for holding and calming patients before, during, and after bladder catheterization and educate healthcare providers in these practices when indicated.
• Consistently adhere to infection control practices.
• Identify complications and respond with appropriate actions.
• Distinguish the need for and efficiently access appropriate consultants and support services for assistance with analgesia, sedation, anxiolysis, and performance of a bladder catheterization.
• Diagnose pediatric conditions, such as UTI, nephrotic syndrome, glomerulonephritis, diabetes mellitus, and others, through effective interpretation of a UA.

Pediatric hospitalists should be able to:

• Realize the importance of obtaining a sterile urine specimen to correctly diagnose urinary tract infection.
• Realize the importance of effective communication with patients and the family/caregivers regarding the indications for, risks, benefits, and steps of bladder catheterization.
• Appreciate the need for collaboration with nurses, learners and other healthcare providers, to promote the use of evidence-based practices in maintenance of urinary catheters to decrease risk of CAUTIs in the inpatient setting.
• Exemplify appropriate adherence to and advocate for strict 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 bladder catheterization in children.
• Lead, coordinate, or participate in the development and implementation of educational initiatives designed to teach the proper technique for bladder catheterization as well as safe catheter maintenance when prolonged catheterization is required.

Introduction

Bladder catheterization is a commonly performed procedure, typically used to collect a sterile urine sample for analysis and culture when urinary tract infection (UTI) is suspected. Bladder catheterization is also used to relieve urinary retention or obstruction, particularly in cases of anatomic abnormalities or neurogenic bladder, or to monitor urine output and overall fluid status. Pediatric hospitalists frequently encounter patients requiring bladder catheterization, and in many practice settings, may need to be adept at performing this procedure in infants, children, and adolescents. While not all pediatric hospitalists will regularly perform bladder catheterization, all will be required to interpret urinalysis (UA) in routine practice. A UA is most commonly used to diagnose UTI but can also be used to detect a wide range of pediatric conditions, including primary renal disease, trauma, diabetes, and metabolic disease. The ability to effectively interpret a urinalysis in the inpatient setting remains a core skill for the pediatric hospitalist.

Pediatric hospitalists should be able to:

• Review the basic anatomy of the male and female genitourinary tract.
• Discuss the indications and contraindications for bladder catheterization.
• Describe how the method used to collect a urine specimen can affect interpretation of urine culture results.
• Explain why bladder catheterization is the preferred method of collection in infants and children who cannot reliably produce a voided specimen or in whom a sterile sample is needed.
• Compare and contrast the implications of using different methods to collect a urine specimen, including the varied ability to correctly interpret the UA and culture.
• Describe the steps in performing bladder catheterization for both male and female patients, attending to aspects such as patient identification, sterile technique, patient positioning, equipment needs, and specimen handling.
• Describe the risks and complications associated with bladder catheterization, including localized trauma, creation of a false passage, and potential stricture formation.
• Discuss the indications for analgesia, sedation, or anxiolysis and the medications that may be used for each.
• Describe the indications and risks of indwelling bladder catheters and the criteria for removal.
• Describe best practices and care bundles that can minimize the risk of catheter associated urinary tract infections (CAUTIs).
• Review the indications for consultation with a urologist for bladder catheterization, including known genitourinary tract abnormality, recent genitourinary surgery, or urethral trauma.
• Define a UTI in terms of minimum bacterial colony counts needed with different methods of obtaining the sample, such as catheterization, clean catch, and clean bag.
• Discuss the importance of appropriate specimen handling and the potential effect on culture results.
• Discuss the different components of a urinalysis, including specific gravity, white and red blood cell counts, protein, casts, and glucose, including how each can be used to detect and manage different pediatric conditions.
• Compare and contrast the sensitivity, specificity, and positive or negative predictive value of the leukocyte esterase and nitrite components of a UA in the diagnosis of UTI.

Pediatric hospitalists should be able to:

• Perform a pre-procedural evaluation to determine risks and benefits of bladder catheterization.
• Demonstrate proficiency in performance of bladder catheterization on infants, children, and adolescents, when required according to local practice.
• Identify the level of pain and anxiety provoked by the procedure and provide appropriate pharmacologic or nonpharmacologic interventions when indicated.
• Employ proper techniques for holding and calming patients before, during, and after bladder catheterization and educate healthcare providers in these practices when indicated.
• Consistently adhere to infection control practices.
• Identify complications and respond with appropriate actions.
• Distinguish the need for and efficiently access appropriate consultants and support services for assistance with analgesia, sedation, anxiolysis, and performance of a bladder catheterization.
• Diagnose pediatric conditions, such as UTI, nephrotic syndrome, glomerulonephritis, diabetes mellitus, and others, through effective interpretation of a UA.

Pediatric hospitalists should be able to:

• Realize the importance of obtaining a sterile urine specimen to correctly diagnose urinary tract infection.
• Realize the importance of effective communication with patients and the family/caregivers regarding the indications for, risks, benefits, and steps of bladder catheterization.
• Appreciate the need for collaboration with nurses, learners and other healthcare providers, to promote the use of evidence-based practices in maintenance of urinary catheters to decrease risk of CAUTIs in the inpatient setting.
• Exemplify appropriate adherence to and advocate for strict 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 bladder catheterization in children.
• Lead, coordinate, or participate in the development and implementation of educational initiatives designed to teach the proper technique for bladder catheterization as well as safe catheter maintenance when prolonged catheterization is required.

Introduction

Urinary tract infections (UTI) can involve any structure from the kidney to the urethra and occur in up to 2.8% of all children and 5% of febrile infants. According to the latest estimates from the Agency for Healthcare Research and Quality’s Kid Inpatient Database, more than 40,000 children aged 0-18 years were hospitalized in 2016 because of a UTI. The rate is highest in very young infants who present with unexplained fever and is particularly high in girls and uncircumcised boys. Infants younger than 1 year of age account for more than 30% of UTI hospitalizations. Most UTI can be treated as an outpatient; indications for inpatient treatment include age less than 1-2 months, dehydration, inability to tolerate oral antibiotics, and concern for serious complication (such as renal abscess, obstructive uropathy, urosepsis, and others). Pediatric hospitalists frequently encounter children with UTI and must remain current on strategies for diagnosis, treatment, and follow-up care.

Pediatric hospitalists should be able to:

• Describe the abnormal anatomic and physiologic aspects of the urogenital system that may predispose children to UTI at varying ages, such as vesicoureteral reflux, posterior urethral valves, constipation, voiding dysfunction (including neurologic causes), and others.
• Describe the range of clinical presentations attending to differences in age.
• Compare and contrast lower (cystitis) versus upper (pyelonephritis) UTI.
• Explain indications for admission of a child with UTI, such as young age, dehydration, sepsis, suspected serious complication, and others.
• List uropathogens that cause UTI in both previously healthy hosts and those with underlying disease.
• Discuss the utility and limitations of commonly obtained laboratory tests, such as urinalysis, urine culture, blood culture, serum chemistries, and others.
• Specify appropriate antimicrobial coverage for common uropathogens, with awareness of antimicrobial resistance patterns within the local community.
• Describe the indications for screening for underlying anatomic abnormalities, especially for children with a first UTI.
• Discuss the utility and limitations of various imaging modalities, including ultrasonography, voiding cystourethrography, and nuclear scintigraphy.
• Describe the typical response to therapy, including common complications to consider if response is atypical.
• Summarize current literature regarding treatment and evaluation for underlying abnormalities.
• List indications for subspecialty consultation or referral.
• Summarize the discharge plan regarding continued antimicrobial therapy, need for antimicrobial prophylaxis, and follow-up.

Pediatric hospitalists should be able to:

• Identify patients at risk for UTI.
• Use the appropriate urine collection method attending to patient’s age, voiding function, and clinical condition.
• Prescribe appropriate initial antimicrobial and supportive therapy.
• Interpret results of diagnostic testing and use results to guide diagnosis and management.
• Identify when consultation is appropriate and efficiently access appropriate support services needed to provide comprehensive care.
• Establish discharge criteria, including medical and social considerations, and identify when they are met.
• Create a discharge plan that includes contingency instructions, medications, and follow-up as appropriate.
• Communicate effectively with patients, the family/caregivers, and the primary care provider regarding the expected course of illness, treatment options, possible sequelae, and the importance of both short-term and longer-term follow-up.

Pediatric hospitalists should be able to:

• Recognize the importance of communicating with the patients, the family/caregivers, and the primary care provider to assure a safe, efficient, and effective discharge and post-discharge care.
• Exemplify collaborative practice with the healthcare team to ensure coordinated hospital care for children with UTI.

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

• Collaborate with referring physicians (primary care, emergency medicine, specialists, and other hospital physicians) to develop and sustain appropriate referral networks for evaluation, admission, or transfer of children with UTI.
• Collaborate with subspecialists when appropriate, to ensure consistent, timely, and up-to-date evaluation and care in the inpatient setting and after discharge.
• Lead, coordinate, or participate in the development and implementation of cost-effective, safe, evidence-based care pathways to standardize the evaluation and management of hospitalized children with UTI.
• Collaborate with laboratory and radiology directors and staff to ensure the availability of systems for timely evaluation of specimens and performance and interpretation of appropriate evaluation studies.

Introduction

Urinary tract infections (UTI) can involve any structure from the kidney to the urethra and occur in up to 2.8% of all children and 5% of febrile infants. According to the latest estimates from the Agency for Healthcare Research and Quality’s Kid Inpatient Database, more than 40,000 children aged 0-18 years were hospitalized in 2016 because of a UTI. The rate is highest in very young infants who present with unexplained fever and is particularly high in girls and uncircumcised boys. Infants younger than 1 year of age account for more than 30% of UTI hospitalizations. Most UTI can be treated as an outpatient; indications for inpatient treatment include age less than 1-2 months, dehydration, inability to tolerate oral antibiotics, and concern for serious complication (such as renal abscess, obstructive uropathy, urosepsis, and others). Pediatric hospitalists frequently encounter children with UTI and must remain current on strategies for diagnosis, treatment, and follow-up care.

Pediatric hospitalists should be able to:

• Describe the abnormal anatomic and physiologic aspects of the urogenital system that may predispose children to UTI at varying ages, such as vesicoureteral reflux, posterior urethral valves, constipation, voiding dysfunction (including neurologic causes), and others.
• Describe the range of clinical presentations attending to differences in age.
• Compare and contrast lower (cystitis) versus upper (pyelonephritis) UTI.
• Explain indications for admission of a child with UTI, such as young age, dehydration, sepsis, suspected serious complication, and others.
• List uropathogens that cause UTI in both previously healthy hosts and those with underlying disease.
• Discuss the utility and limitations of commonly obtained laboratory tests, such as urinalysis, urine culture, blood culture, serum chemistries, and others.
• Specify appropriate antimicrobial coverage for common uropathogens, with awareness of antimicrobial resistance patterns within the local community.
• Describe the indications for screening for underlying anatomic abnormalities, especially for children with a first UTI.
• Discuss the utility and limitations of various imaging modalities, including ultrasonography, voiding cystourethrography, and nuclear scintigraphy.
• Describe the typical response to therapy, including common complications to consider if response is atypical.
• Summarize current literature regarding treatment and evaluation for underlying abnormalities.
• List indications for subspecialty consultation or referral.
• Summarize the discharge plan regarding continued antimicrobial therapy, need for antimicrobial prophylaxis, and follow-up.

Pediatric hospitalists should be able to:

• Identify patients at risk for UTI.
• Use the appropriate urine collection method attending to patient’s age, voiding function, and clinical condition.
• Prescribe appropriate initial antimicrobial and supportive therapy.
• Interpret results of diagnostic testing and use results to guide diagnosis and management.
• Identify when consultation is appropriate and efficiently access appropriate support services needed to provide comprehensive care.
• Establish discharge criteria, including medical and social considerations, and identify when they are met.
• Create a discharge plan that includes contingency instructions, medications, and follow-up as appropriate.
• Communicate effectively with patients, the family/caregivers, and the primary care provider regarding the expected course of illness, treatment options, possible sequelae, and the importance of both short-term and longer-term follow-up.

Pediatric hospitalists should be able to:

• Recognize the importance of communicating with the patients, the family/caregivers, and the primary care provider to assure a safe, efficient, and effective discharge and post-discharge care.
• Exemplify collaborative practice with the healthcare team to ensure coordinated hospital care for children with UTI.

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

• Collaborate with referring physicians (primary care, emergency medicine, specialists, and other hospital physicians) to develop and sustain appropriate referral networks for evaluation, admission, or transfer of children with UTI.
• Collaborate with subspecialists when appropriate, to ensure consistent, timely, and up-to-date evaluation and care in the inpatient setting and after discharge.
• Lead, coordinate, or participate in the development and implementation of cost-effective, safe, evidence-based care pathways to standardize the evaluation and management of hospitalized children with UTI.
• Collaborate with laboratory and radiology directors and staff to ensure the availability of systems for timely evaluation of specimens and performance and interpretation of appropriate evaluation studies.

Introduction

Urinary tract infections (UTI) can involve any structure from the kidney to the urethra and occur in up to 2.8% of all children and 5% of febrile infants. According to the latest estimates from the Agency for Healthcare Research and Quality’s Kid Inpatient Database, more than 40,000 children aged 0-18 years were hospitalized in 2016 because of a UTI. The rate is highest in very young infants who present with unexplained fever and is particularly high in girls and uncircumcised boys. Infants younger than 1 year of age account for more than 30% of UTI hospitalizations. Most UTI can be treated as an outpatient; indications for inpatient treatment include age less than 1-2 months, dehydration, inability to tolerate oral antibiotics, and concern for serious complication (such as renal abscess, obstructive uropathy, urosepsis, and others). Pediatric hospitalists frequently encounter children with UTI and must remain current on strategies for diagnosis, treatment, and follow-up care.

Pediatric hospitalists should be able to:

• Describe the abnormal anatomic and physiologic aspects of the urogenital system that may predispose children to UTI at varying ages, such as vesicoureteral reflux, posterior urethral valves, constipation, voiding dysfunction (including neurologic causes), and others.
• Describe the range of clinical presentations attending to differences in age.
• Compare and contrast lower (cystitis) versus upper (pyelonephritis) UTI.
• Explain indications for admission of a child with UTI, such as young age, dehydration, sepsis, suspected serious complication, and others.
• List uropathogens that cause UTI in both previously healthy hosts and those with underlying disease.
• Discuss the utility and limitations of commonly obtained laboratory tests, such as urinalysis, urine culture, blood culture, serum chemistries, and others.
• Specify appropriate antimicrobial coverage for common uropathogens, with awareness of antimicrobial resistance patterns within the local community.
• Describe the indications for screening for underlying anatomic abnormalities, especially for children with a first UTI.
• Discuss the utility and limitations of various imaging modalities, including ultrasonography, voiding cystourethrography, and nuclear scintigraphy.
• Describe the typical response to therapy, including common complications to consider if response is atypical.
• Summarize current literature regarding treatment and evaluation for underlying abnormalities.
• List indications for subspecialty consultation or referral.
• Summarize the discharge plan regarding continued antimicrobial therapy, need for antimicrobial prophylaxis, and follow-up.

Pediatric hospitalists should be able to:

• Identify patients at risk for UTI.
• Use the appropriate urine collection method attending to patient’s age, voiding function, and clinical condition.
• Prescribe appropriate initial antimicrobial and supportive therapy.
• Interpret results of diagnostic testing and use results to guide diagnosis and management.
• Identify when consultation is appropriate and efficiently access appropriate support services needed to provide comprehensive care.
• Establish discharge criteria, including medical and social considerations, and identify when they are met.
• Create a discharge plan that includes contingency instructions, medications, and follow-up as appropriate.
• Communicate effectively with patients, the family/caregivers, and the primary care provider regarding the expected course of illness, treatment options, possible sequelae, and the importance of both short-term and longer-term follow-up.

Pediatric hospitalists should be able to:

• Recognize the importance of communicating with the patients, the family/caregivers, and the primary care provider to assure a safe, efficient, and effective discharge and post-discharge care.
• Exemplify collaborative practice with the healthcare team to ensure coordinated hospital care for children with UTI.

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

• Collaborate with referring physicians (primary care, emergency medicine, specialists, and other hospital physicians) to develop and sustain appropriate referral networks for evaluation, admission, or transfer of children with UTI.
• Collaborate with subspecialists when appropriate, to ensure consistent, timely, and up-to-date evaluation and care in the inpatient setting and after discharge.
• Lead, coordinate, or participate in the development and implementation of cost-effective, safe, evidence-based care pathways to standardize the evaluation and management of hospitalized children with UTI.
• Collaborate with laboratory and radiology directors and staff to ensure the availability of systems for timely evaluation of specimens and performance and interpretation of appropriate evaluation studies.

Introduction

In 2016, the National Data Poison System captured more than 4 million calls to poison control centers in the United States, 2.2 million of which were calls regarding human exposures. Close to 50% of reported toxin exposures occur in children under age 6 years.Furthermore, ingestion accounts for 75% of all toxin exposures in younger children. In this age group, toxin ingestion is frequently unintentional and involves non-pharmacologic agents, but therapeutic errors in the administration of pharmacologic agents do occur. In adolescents, toxin ingestion is more often intentional or secondary to substance abuse and is associated with greater morbidity and mortality, particularly when pharmacological agents are involved. Pediatric hospitalists often provide immediate care, coordinate care with subspecialists, and arrange for transfer to another facility when appropriate.

Pediatric hospitalists should be able to:

• List the pharmacologic and non-pharmacologic agents commonly ingested by pediatric patients, including how the relative frequency of each changes with age.
• Compare and contrast the risk factors and comorbidities associated with unintentional versus intentional ingestion.
• Describe the signs and symptoms of acute ingestion, including known toxidromes for commonly ingested agents such as salicylates, acetaminophen, narcotics, hallucinogens, stimulants, and others.
• Discuss the risk factors for and presentation of acute and chronic lead poisoning.
• List common laboratory tests that aid the diagnosis or assist with the management of common exposures and ingestions.
• List the agents detected in locally available blood and urine toxicology screens, including the benefits and limitations of this testing.
• Describe the benefits of comprehensive drug screens, attending to which screens are available to be sent from local institutions.
• Explain the indications for and limitations of decontamination therapy, including dermal, ocular, and gastric decontamination methods.
• Identify toxins that have a specific antidote available, including the indications and limitations of each.
• List local resources that provide information and advice regarding pediatric toxin exposure and ingestion management, acknowledging that there is a single phone number in the United States to access all regional poison center resources.
• Summarize the indications and goals of hospitalization, attending to acute and chronic medical needs and psychosocial intervention.
• Describe elements of a safe discharge for patients with toxic ingestion or exposure, including pre-discharge psychiatric and substance abuse evaluation, establishment of outpatient providers, development of a home safety plan, and others as indicated.
• Discuss risk factors for opioid and other prescription medication misuse and abuse.
• Identify locations and other local resources for safe medication disposal in the community.

Pediatric hospitalists should be able to:

• Obtain a focused history, including detailed information about the type, quantity, timing, and duration of potential exposures and ingestions.
• Perform a focused physical examination, with attention paid to signs and symptoms that may indicate exposure or ingestion of a particular toxin.
• Access institutional and local resources to obtain information and advice regarding the diagnosis and management of acute ingestion.
• Identify patients presenting with common toxidromes and efficiently institute appropriate therapy.
• Identify life-threatening complications of exposures or ingestions, such as cardiac dysrhythmias, respiratory depression, or mental status change, instituting appropriate therapy in a timely fashion.
• Recognize potential co-morbidities associated with intentional ingestion, such as depression, abuse, or other mental illness.
• Order and interpret basic tests, such as serum chemistries, blood gases, and electrocardiograms, and identify abnormal findings that require additional testing or consultation.
• Develop an appropriate treatment plan based on the presumptive or confirmed agent and provide decontamination or antidote therapy when appropriate.
• Determine the appropriate level of care and duration of observation for a given toxin, understanding that some agents may have delayed toxic effects.
• Consult subspecialists, including social work and/or psychiatry, for care of non-accidental ingestion as appropriate.
• Identify patients at high risk of opioid and other prescription medication misuse and abuse, efficiently utilizing state monitoring websites when appropriate.
• Counsel the family/caregivers in safe medication practices and disposal.

Pediatric hospitalists should be able to:

• Realize the importance of counseling the family/caregivers and other professional staff on the possible etiology and outcomes of an exposure or ingestion episode.
• Consider the social environment to determine the risk of future exposure or ingestion and the need for mitigation of risk factors prior to discharge.
• Reflect on the importance of educating the family/caregivers regarding proactive risk reduction measures, such as the safe and effective storage, use, and administration of medications, and potential availability of reversal agents in the home environment.
• Realize the importance of remaining vigilant regarding changes in recreational drug availability and use, as well as safety profile updates on pharmacologic and non-pharmacologic agents.

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

• Lead, coordinate, or participate in the development of systems that integrate hospital, community, and national resources to provide up-to-date and evidence-based information about toxin exposures and ingestions, promoting timely recognition and treatment of both intentional and unintentional events.
• Lead, coordinate, or participate in efforts to educate healthcare providers about the most common exposures and ingestions in the pediatric population.
• Lead, coordinate, or participate in efforts to educate healthcare providers and the community regarding ways to mitigate medication errors.
• Lead, coordinate, or participate in efforts to educate healthcare providers and the community in safe opioid prescribing during the transition of care from the hospital to outpatient setting.

Introduction

In 2016, the National Data Poison System captured more than 4 million calls to poison control centers in the United States, 2.2 million of which were calls regarding human exposures. Close to 50% of reported toxin exposures occur in children under age 6 years.Furthermore, ingestion accounts for 75% of all toxin exposures in younger children. In this age group, toxin ingestion is frequently unintentional and involves non-pharmacologic agents, but therapeutic errors in the administration of pharmacologic agents do occur. In adolescents, toxin ingestion is more often intentional or secondary to substance abuse and is associated with greater morbidity and mortality, particularly when pharmacological agents are involved. Pediatric hospitalists often provide immediate care, coordinate care with subspecialists, and arrange for transfer to another facility when appropriate.

Pediatric hospitalists should be able to:

• List the pharmacologic and non-pharmacologic agents commonly ingested by pediatric patients, including how the relative frequency of each changes with age.
• Compare and contrast the risk factors and comorbidities associated with unintentional versus intentional ingestion.
• Describe the signs and symptoms of acute ingestion, including known toxidromes for commonly ingested agents such as salicylates, acetaminophen, narcotics, hallucinogens, stimulants, and others.
• Discuss the risk factors for and presentation of acute and chronic lead poisoning.
• List common laboratory tests that aid the diagnosis or assist with the management of common exposures and ingestions.
• List the agents detected in locally available blood and urine toxicology screens, including the benefits and limitations of this testing.
• Describe the benefits of comprehensive drug screens, attending to which screens are available to be sent from local institutions.
• Explain the indications for and limitations of decontamination therapy, including dermal, ocular, and gastric decontamination methods.
• Identify toxins that have a specific antidote available, including the indications and limitations of each.
• List local resources that provide information and advice regarding pediatric toxin exposure and ingestion management, acknowledging that there is a single phone number in the United States to access all regional poison center resources.
• Summarize the indications and goals of hospitalization, attending to acute and chronic medical needs and psychosocial intervention.
• Describe elements of a safe discharge for patients with toxic ingestion or exposure, including pre-discharge psychiatric and substance abuse evaluation, establishment of outpatient providers, development of a home safety plan, and others as indicated.
• Discuss risk factors for opioid and other prescription medication misuse and abuse.
• Identify locations and other local resources for safe medication disposal in the community.

Pediatric hospitalists should be able to:

• Obtain a focused history, including detailed information about the type, quantity, timing, and duration of potential exposures and ingestions.
• Perform a focused physical examination, with attention paid to signs and symptoms that may indicate exposure or ingestion of a particular toxin.
• Access institutional and local resources to obtain information and advice regarding the diagnosis and management of acute ingestion.
• Identify patients presenting with common toxidromes and efficiently institute appropriate therapy.
• Identify life-threatening complications of exposures or ingestions, such as cardiac dysrhythmias, respiratory depression, or mental status change, instituting appropriate therapy in a timely fashion.
• Recognize potential co-morbidities associated with intentional ingestion, such as depression, abuse, or other mental illness.
• Order and interpret basic tests, such as serum chemistries, blood gases, and electrocardiograms, and identify abnormal findings that require additional testing or consultation.
• Develop an appropriate treatment plan based on the presumptive or confirmed agent and provide decontamination or antidote therapy when appropriate.
• Determine the appropriate level of care and duration of observation for a given toxin, understanding that some agents may have delayed toxic effects.
• Consult subspecialists, including social work and/or psychiatry, for care of non-accidental ingestion as appropriate.
• Identify patients at high risk of opioid and other prescription medication misuse and abuse, efficiently utilizing state monitoring websites when appropriate.
• Counsel the family/caregivers in safe medication practices and disposal.

Pediatric hospitalists should be able to:

• Realize the importance of counseling the family/caregivers and other professional staff on the possible etiology and outcomes of an exposure or ingestion episode.
• Consider the social environment to determine the risk of future exposure or ingestion and the need for mitigation of risk factors prior to discharge.
• Reflect on the importance of educating the family/caregivers regarding proactive risk reduction measures, such as the safe and effective storage, use, and administration of medications, and potential availability of reversal agents in the home environment.
• Realize the importance of remaining vigilant regarding changes in recreational drug availability and use, as well as safety profile updates on pharmacologic and non-pharmacologic agents.

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

• Lead, coordinate, or participate in the development of systems that integrate hospital, community, and national resources to provide up-to-date and evidence-based information about toxin exposures and ingestions, promoting timely recognition and treatment of both intentional and unintentional events.
• Lead, coordinate, or participate in efforts to educate healthcare providers about the most common exposures and ingestions in the pediatric population.
• Lead, coordinate, or participate in efforts to educate healthcare providers and the community regarding ways to mitigate medication errors.
• Lead, coordinate, or participate in efforts to educate healthcare providers and the community in safe opioid prescribing during the transition of care from the hospital to outpatient setting.

Introduction

In 2016, the National Data Poison System captured more than 4 million calls to poison control centers in the United States, 2.2 million of which were calls regarding human exposures. Close to 50% of reported toxin exposures occur in children under age 6 years.Furthermore, ingestion accounts for 75% of all toxin exposures in younger children. In this age group, toxin ingestion is frequently unintentional and involves non-pharmacologic agents, but therapeutic errors in the administration of pharmacologic agents do occur. In adolescents, toxin ingestion is more often intentional or secondary to substance abuse and is associated with greater morbidity and mortality, particularly when pharmacological agents are involved. Pediatric hospitalists often provide immediate care, coordinate care with subspecialists, and arrange for transfer to another facility when appropriate.

Pediatric hospitalists should be able to:

• List the pharmacologic and non-pharmacologic agents commonly ingested by pediatric patients, including how the relative frequency of each changes with age.
• Compare and contrast the risk factors and comorbidities associated with unintentional versus intentional ingestion.
• Describe the signs and symptoms of acute ingestion, including known toxidromes for commonly ingested agents such as salicylates, acetaminophen, narcotics, hallucinogens, stimulants, and others.
• Discuss the risk factors for and presentation of acute and chronic lead poisoning.
• List common laboratory tests that aid the diagnosis or assist with the management of common exposures and ingestions.
• List the agents detected in locally available blood and urine toxicology screens, including the benefits and limitations of this testing.
• Describe the benefits of comprehensive drug screens, attending to which screens are available to be sent from local institutions.
• Explain the indications for and limitations of decontamination therapy, including dermal, ocular, and gastric decontamination methods.
• Identify toxins that have a specific antidote available, including the indications and limitations of each.
• List local resources that provide information and advice regarding pediatric toxin exposure and ingestion management, acknowledging that there is a single phone number in the United States to access all regional poison center resources.
• Summarize the indications and goals of hospitalization, attending to acute and chronic medical needs and psychosocial intervention.
• Describe elements of a safe discharge for patients with toxic ingestion or exposure, including pre-discharge psychiatric and substance abuse evaluation, establishment of outpatient providers, development of a home safety plan, and others as indicated.
• Discuss risk factors for opioid and other prescription medication misuse and abuse.
• Identify locations and other local resources for safe medication disposal in the community.

Pediatric hospitalists should be able to:

• Obtain a focused history, including detailed information about the type, quantity, timing, and duration of potential exposures and ingestions.
• Perform a focused physical examination, with attention paid to signs and symptoms that may indicate exposure or ingestion of a particular toxin.
• Access institutional and local resources to obtain information and advice regarding the diagnosis and management of acute ingestion.
• Identify patients presenting with common toxidromes and efficiently institute appropriate therapy.
• Identify life-threatening complications of exposures or ingestions, such as cardiac dysrhythmias, respiratory depression, or mental status change, instituting appropriate therapy in a timely fashion.
• Recognize potential co-morbidities associated with intentional ingestion, such as depression, abuse, or other mental illness.
• Order and interpret basic tests, such as serum chemistries, blood gases, and electrocardiograms, and identify abnormal findings that require additional testing or consultation.
• Develop an appropriate treatment plan based on the presumptive or confirmed agent and provide decontamination or antidote therapy when appropriate.
• Determine the appropriate level of care and duration of observation for a given toxin, understanding that some agents may have delayed toxic effects.
• Consult subspecialists, including social work and/or psychiatry, for care of non-accidental ingestion as appropriate.
• Identify patients at high risk of opioid and other prescription medication misuse and abuse, efficiently utilizing state monitoring websites when appropriate.
• Counsel the family/caregivers in safe medication practices and disposal.

Pediatric hospitalists should be able to:

• Realize the importance of counseling the family/caregivers and other professional staff on the possible etiology and outcomes of an exposure or ingestion episode.
• Consider the social environment to determine the risk of future exposure or ingestion and the need for mitigation of risk factors prior to discharge.
• Reflect on the importance of educating the family/caregivers regarding proactive risk reduction measures, such as the safe and effective storage, use, and administration of medications, and potential availability of reversal agents in the home environment.
• Realize the importance of remaining vigilant regarding changes in recreational drug availability and use, as well as safety profile updates on pharmacologic and non-pharmacologic agents.

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

• Lead, coordinate, or participate in the development of systems that integrate hospital, community, and national resources to provide up-to-date and evidence-based information about toxin exposures and ingestions, promoting timely recognition and treatment of both intentional and unintentional events.
• Lead, coordinate, or participate in efforts to educate healthcare providers about the most common exposures and ingestions in the pediatric population.
• Lead, coordinate, or participate in efforts to educate healthcare providers and the community regarding ways to mitigate medication errors.
• Lead, coordinate, or participate in efforts to educate healthcare providers and the community in safe opioid prescribing during the transition of care from the hospital to outpatient setting.

Introduction

Skin and soft tissue infections are infections of the skin, subcutaneous tissue, and muscle, such as cellulitis or abscess. They do not include infections of the bone, ligaments, cartilage, and fibrous tissue. Pediatric skin and soft tissue hospitalizations have increased in incidence over the previous two decades and are responsible for significant resource utilization. The most common infectious etiologies of soft tissue infections are Streptococcus or Staphylococcus species, traditionally treated with Beta-lactam antibiotics. However, infections due to methicillin-resistant Staphylococcus aureus, particularly community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA), and other organisms are on the rise. Pediatric hospitalists should be knowledgeable about the diagnosis and treatment of skin and soft tissue infections, including the changing epidemiology of pathogens and resistance patterns, to ensure efficient and effective treatment of these infections.

Pediatric hospitalists should be able to:

• Compare and contrast the key features of the history and physical examination noted in cellulitis versus deeper soft tissue infection.
• Provide indications for hospital admission and determine the appropriate level of care.
• List common bacterial organisms causing skin and soft tissues infections, including how these differ based on age and exposure histories.
• Describe risk factors for infection such as host immunity, dermatoses, environmental exposures, and others.
• Discuss the influence of community prevalence of skin pathogens and antimicrobial use on predominant organisms and resistance patterns.
• Review how patient and antibiotic characteristics and potential complications of skin and soft tissue infections may influence antibiotic and other treatment choices.
• Discuss how culture and identification of the organism and susceptibility pattern aids in treatment decisions when applicable.
• Compare and contrast emergent versus urgent complications requiring pediatric surgery consultation, such as necrotizing fasciitis and abscesses.
• Explain why early identification and surgical intervention in necrotizing fasciitis can improve outcomes.
• Compare and contrast the utility of various imaging modalities such as plain film, ultrasound, nuclear medicine scan, computed tomography, and magnetic resonance imaging, including indications for each.
• Summarize the approach toward evaluation and treatment of patients with recurrent Staphylococcal infections, including indications for evaluation for systemic disease, household colonization, and environmental exposures.

Pediatric hospitalists should be able to:

• Elicit a medical history to identify detailed information about onset and timing of spread of infection, history of similar infections, and specific exposures.
• Demonstrate proficiency in conducting a physical examination of skin and soft tissue infections to determine extent and severity of the infection, including the presence of a phlegmon or abscess.
• Identify and demarcate the borders of the infection to assist with assessing further spread.
• Order appropriate laboratory and radiographic tests to guide treatment and ensure proper isolation.
• Interpret radiographic studies and engage consultants when appropriate.
• Direct an evidence-based treatment plan including appropriately selected antibiotic therapy, attending to the most likely organisms and antibiotic susceptibility patterns.
• Perform careful reassessments daily and as needed, note changes in clinical status, and respond with appropriate actions.
• Adjust antibiotics according to the identification of the organism and/or antibiotic susceptibility pattern and clinical progression/improvement.
• Demonstrate proficiency in incision and drainage of simple cutaneous abscesses, including use of appropriate analgesia, anxiolysis, and/or procedural sedation, according to local practice parameters.
• Consult appropriate subspecialists, including surgeons, radiologists, and others, to assist in evaluation and treatment as appropriate.
• Identify patients requiring extended evaluation for underlying anatomic or systemic disease.
• Create a comprehensive discharge plan, including home care as appropriate.

Pediatric hospitalists should be able to:

• Recognize the importance of consulting with interdisciplinary teams, such as pediatric surgeons, radiologists, pharmacists, and the laboratory, early in the hospital course to facilitate rapid diagnosis, treatment, and discharge.
• Acknowledge the value of effective communication with patients, the family/caregivers, primary care provider, and subspecialists regarding the reasons for diagnostic testing and treatment choices.
• Realize the importance of educating the family/caregivers on the etiology of the infection, including the importance of hand washing and minimizing environmental exposure in the prevention of infection.
• Role model proactive, engaged behavior regarding proper isolation measures to prevent spread of the etiologic agent in the hospital.
• Realize the importance of antimicrobial stewardship and consistently modify prescribing practice to reflect best practices attending to local resistance patterns.

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

• Work with hospital administration and subspecialists to acquire local laboratory testing that is critical for evaluation and management, such as susceptibility testing.
• Incorporate knowledge of outcomes research, changing microbial epidemiology and resistance patterns, cost, and management strategies into patient care.

• Lead, coordinate, or participate in the development and implementation of cost-effective, safe, evidence-based care pathways to standardize the evaluation and management of skin and soft tissue infections.

Introduction

Skin and soft tissue infections are infections of the skin, subcutaneous tissue, and muscle, such as cellulitis or abscess. They do not include infections of the bone, ligaments, cartilage, and fibrous tissue. Pediatric skin and soft tissue hospitalizations have increased in incidence over the previous two decades and are responsible for significant resource utilization. The most common infectious etiologies of soft tissue infections are Streptococcus or Staphylococcus species, traditionally treated with Beta-lactam antibiotics. However, infections due to methicillin-resistant Staphylococcus aureus, particularly community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA), and other organisms are on the rise. Pediatric hospitalists should be knowledgeable about the diagnosis and treatment of skin and soft tissue infections, including the changing epidemiology of pathogens and resistance patterns, to ensure efficient and effective treatment of these infections.

Pediatric hospitalists should be able to:

• Compare and contrast the key features of the history and physical examination noted in cellulitis versus deeper soft tissue infection.
• Provide indications for hospital admission and determine the appropriate level of care.
• List common bacterial organisms causing skin and soft tissues infections, including how these differ based on age and exposure histories.
• Describe risk factors for infection such as host immunity, dermatoses, environmental exposures, and others.
• Discuss the influence of community prevalence of skin pathogens and antimicrobial use on predominant organisms and resistance patterns.
• Review how patient and antibiotic characteristics and potential complications of skin and soft tissue infections may influence antibiotic and other treatment choices.
• Discuss how culture and identification of the organism and susceptibility pattern aids in treatment decisions when applicable.
• Compare and contrast emergent versus urgent complications requiring pediatric surgery consultation, such as necrotizing fasciitis and abscesses.
• Explain why early identification and surgical intervention in necrotizing fasciitis can improve outcomes.
• Compare and contrast the utility of various imaging modalities such as plain film, ultrasound, nuclear medicine scan, computed tomography, and magnetic resonance imaging, including indications for each.
• Summarize the approach toward evaluation and treatment of patients with recurrent Staphylococcal infections, including indications for evaluation for systemic disease, household colonization, and environmental exposures.

Pediatric hospitalists should be able to:

• Elicit a medical history to identify detailed information about onset and timing of spread of infection, history of similar infections, and specific exposures.
• Demonstrate proficiency in conducting a physical examination of skin and soft tissue infections to determine extent and severity of the infection, including the presence of a phlegmon or abscess.
• Identify and demarcate the borders of the infection to assist with assessing further spread.
• Order appropriate laboratory and radiographic tests to guide treatment and ensure proper isolation.
• Interpret radiographic studies and engage consultants when appropriate.
• Direct an evidence-based treatment plan including appropriately selected antibiotic therapy, attending to the most likely organisms and antibiotic susceptibility patterns.
• Perform careful reassessments daily and as needed, note changes in clinical status, and respond with appropriate actions.
• Adjust antibiotics according to the identification of the organism and/or antibiotic susceptibility pattern and clinical progression/improvement.
• Demonstrate proficiency in incision and drainage of simple cutaneous abscesses, including use of appropriate analgesia, anxiolysis, and/or procedural sedation, according to local practice parameters.
• Consult appropriate subspecialists, including surgeons, radiologists, and others, to assist in evaluation and treatment as appropriate.
• Identify patients requiring extended evaluation for underlying anatomic or systemic disease.
• Create a comprehensive discharge plan, including home care as appropriate.

Pediatric hospitalists should be able to:

• Recognize the importance of consulting with interdisciplinary teams, such as pediatric surgeons, radiologists, pharmacists, and the laboratory, early in the hospital course to facilitate rapid diagnosis, treatment, and discharge.
• Acknowledge the value of effective communication with patients, the family/caregivers, primary care provider, and subspecialists regarding the reasons for diagnostic testing and treatment choices.
• Realize the importance of educating the family/caregivers on the etiology of the infection, including the importance of hand washing and minimizing environmental exposure in the prevention of infection.
• Role model proactive, engaged behavior regarding proper isolation measures to prevent spread of the etiologic agent in the hospital.
• Realize the importance of antimicrobial stewardship and consistently modify prescribing practice to reflect best practices attending to local resistance patterns.

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

• Work with hospital administration and subspecialists to acquire local laboratory testing that is critical for evaluation and management, such as susceptibility testing.
• Incorporate knowledge of outcomes research, changing microbial epidemiology and resistance patterns, cost, and management strategies into patient care.

• Lead, coordinate, or participate in the development and implementation of cost-effective, safe, evidence-based care pathways to standardize the evaluation and management of skin and soft tissue infections.

Introduction

Skin and soft tissue infections are infections of the skin, subcutaneous tissue, and muscle, such as cellulitis or abscess. They do not include infections of the bone, ligaments, cartilage, and fibrous tissue. Pediatric skin and soft tissue hospitalizations have increased in incidence over the previous two decades and are responsible for significant resource utilization. The most common infectious etiologies of soft tissue infections are Streptococcus or Staphylococcus species, traditionally treated with Beta-lactam antibiotics. However, infections due to methicillin-resistant Staphylococcus aureus, particularly community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA), and other organisms are on the rise. Pediatric hospitalists should be knowledgeable about the diagnosis and treatment of skin and soft tissue infections, including the changing epidemiology of pathogens and resistance patterns, to ensure efficient and effective treatment of these infections.

Pediatric hospitalists should be able to:

• Compare and contrast the key features of the history and physical examination noted in cellulitis versus deeper soft tissue infection.
• Provide indications for hospital admission and determine the appropriate level of care.
• List common bacterial organisms causing skin and soft tissues infections, including how these differ based on age and exposure histories.
• Describe risk factors for infection such as host immunity, dermatoses, environmental exposures, and others.
• Discuss the influence of community prevalence of skin pathogens and antimicrobial use on predominant organisms and resistance patterns.
• Review how patient and antibiotic characteristics and potential complications of skin and soft tissue infections may influence antibiotic and other treatment choices.
• Discuss how culture and identification of the organism and susceptibility pattern aids in treatment decisions when applicable.
• Compare and contrast emergent versus urgent complications requiring pediatric surgery consultation, such as necrotizing fasciitis and abscesses.
• Explain why early identification and surgical intervention in necrotizing fasciitis can improve outcomes.
• Compare and contrast the utility of various imaging modalities such as plain film, ultrasound, nuclear medicine scan, computed tomography, and magnetic resonance imaging, including indications for each.
• Summarize the approach toward evaluation and treatment of patients with recurrent Staphylococcal infections, including indications for evaluation for systemic disease, household colonization, and environmental exposures.

Pediatric hospitalists should be able to:

• Elicit a medical history to identify detailed information about onset and timing of spread of infection, history of similar infections, and specific exposures.
• Demonstrate proficiency in conducting a physical examination of skin and soft tissue infections to determine extent and severity of the infection, including the presence of a phlegmon or abscess.
• Identify and demarcate the borders of the infection to assist with assessing further spread.
• Order appropriate laboratory and radiographic tests to guide treatment and ensure proper isolation.
• Interpret radiographic studies and engage consultants when appropriate.
• Direct an evidence-based treatment plan including appropriately selected antibiotic therapy, attending to the most likely organisms and antibiotic susceptibility patterns.
• Perform careful reassessments daily and as needed, note changes in clinical status, and respond with appropriate actions.
• Adjust antibiotics according to the identification of the organism and/or antibiotic susceptibility pattern and clinical progression/improvement.
• Demonstrate proficiency in incision and drainage of simple cutaneous abscesses, including use of appropriate analgesia, anxiolysis, and/or procedural sedation, according to local practice parameters.
• Consult appropriate subspecialists, including surgeons, radiologists, and others, to assist in evaluation and treatment as appropriate.
• Identify patients requiring extended evaluation for underlying anatomic or systemic disease.
• Create a comprehensive discharge plan, including home care as appropriate.

Pediatric hospitalists should be able to:

• Recognize the importance of consulting with interdisciplinary teams, such as pediatric surgeons, radiologists, pharmacists, and the laboratory, early in the hospital course to facilitate rapid diagnosis, treatment, and discharge.
• Acknowledge the value of effective communication with patients, the family/caregivers, primary care provider, and subspecialists regarding the reasons for diagnostic testing and treatment choices.
• Realize the importance of educating the family/caregivers on the etiology of the infection, including the importance of hand washing and minimizing environmental exposure in the prevention of infection.
• Role model proactive, engaged behavior regarding proper isolation measures to prevent spread of the etiologic agent in the hospital.
• Realize the importance of antimicrobial stewardship and consistently modify prescribing practice to reflect best practices attending to local resistance patterns.

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

• Work with hospital administration and subspecialists to acquire local laboratory testing that is critical for evaluation and management, such as susceptibility testing.
• Incorporate knowledge of outcomes research, changing microbial epidemiology and resistance patterns, cost, and management strategies into patient care.

• Lead, coordinate, or participate in the development and implementation of cost-effective, safe, evidence-based care pathways to standardize the evaluation and management of skin and soft tissue infections.

Introduction

Sickle cell disease is the most common autosomal recessive disease in African American individuals, occurring in 1 in 625 live births to African American couples. While it is most common in African Americans, sickle cell disease also occurs in individuals of Hispanic, Arabic, Native American, and Caucasian heritage. Sickle cell disease results from a single base-pair substitution of thymine for adenine resulting in valine instead of glutamine in the sixth position of the Beta-globin molecule. Sickle cell disease results when this substitution occurs in a homozygous state. Other forms of sickle cell disease with variable severity can also occur when the heterozygote state is combined with a second variant Beta-globin chain such as hemoglobin C or Beta-thalassemia. Clinical manifestations result from polymerization of the abnormal hemoglobin and “sickling” of the red cells. The clinical manifestations most important to pediatric hospitalists include recurrent and chronic pain from dactylitis and vaso-occlusive crisis, acute chest syndrome, increased susceptibility to infections, aplastic crisis, splenic sequestration, stroke, acute hepatobiliary complications, and priapism. Pediatric hospitalists commonly encounter patients with known or suspected sickle cell disease and care for the various complications associated with the disease.

Pediatric hospitalists should be able to:

• Explain the impact of newborn screening on preventive care.
• Review the genetics and pathophysiology underlying the variants of sickle cell disease and their complications.
• Compare and contrast common sickle crisis presentations by age group.
• Describe the signs and symptoms of dactylitis, vaso-occlusive crisis, sepsis, acute chest syndrome, aplastic crisis, splenic sequestration, stroke, acute hepatobiliary complications, and priapism.
• Describe indications for hospital admission and escalation to intensive care.
• Identify the goals of inpatient therapy, attending to both acute and chronic needs.
• Distinguish patients with sickle cell disease presenting with fever who require inpatient management from those who can be safely managed in the outpatient setting.
• Recognize the unique considerations requiring expert consultation for patients with sickle cell disease undergoing surgical procedures.
• Summarize the roles of members of a comprehensive clinical care team, such as patients, the family/caregivers, subspecialty physicians, social worker, pharmacist, physical therapist, discharge planner, psychologist, and others.
• Discuss the therapeutic options available for complications of sickle cell disease, including the rationale for choosing a specific management plan.
• Discuss chronic complications of sickle cell disease, such as chronic pain, neurologic deficits with learning disabilities, hyposthenuria, delayed growth and development, psychosocial issues (including low self-esteem, anxiety, and depression), and others.
• Discuss the evidence-based guidelines for infection prevention, including vaccines and penicillin prophylaxis.
• Discuss medications for prevention and treatment of complications of sickle cell disease, including the use of hydroxyurea and L-glutamine.
• Explain the approach toward acute and chronic pain management, including the use of patient-controlled analgesia and timely transition to oral pain medications.
• Cite reasons for transfer to a referral center in cases requiring pediatric-specific services not available at the local facility.

Pediatric hospitalists should be able to:

• Diagnose sickle cell disease and its complications by performing an accurate history and physical examination, identifying cardinal features of the disease presentation and synthesizing information into unified assessment.
• Order appropriate laboratory and radiographic testing based on history and physical examination findings.
• Create a comprehensive evaluation and management plan, including the use of antimicrobial therapy, intravenous fluid hydration, pain management, transfusion therapy, and initiation of cardiovascular and pulmonary supportive care measures when appropriate.
• Identify patients with worsening status and respond with appropriate actions.
• Consult subspecialists in a timely manner when appropriate.
• Create a comprehensive discharge plan that includes clear home instructions, appropriate medications, and follow-up recommendations.

Pediatric hospitalists should be able to:

• Acknowledge the importance of effective communication and education with patients and the family/caregivers regarding the disease process, proposed therapies, expectations of inpatient therapy, and transition of care to the outpatient arena.
• Realize the psychosocial impact on the patient and family members/care givers.
• Recognize the value of collaboration with subspecialists and the primary care provider, to ensure coordinated longitudinal care for children with sickle cell disease.

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

• Collaborate with a multidisciplinary team consisting of subspecialty physicians, social workers, pharmacists, physical therapists, discharge planners, and psychologists to improve quality of care, increase patient satisfaction, and facilitate timely discharge from the acute care setting.
• Identify existing limitations for optimal care within the current hospital setting and work with hospital administration and community partners to develop and sustain appropriate referral systems and coordinated transfers of care.
• Lead, coordinate, or participate in the development of coordinated discharge plans and programs in the local community.

Introduction

Sickle cell disease is the most common autosomal recessive disease in African American individuals, occurring in 1 in 625 live births to African American couples. While it is most common in African Americans, sickle cell disease also occurs in individuals of Hispanic, Arabic, Native American, and Caucasian heritage. Sickle cell disease results from a single base-pair substitution of thymine for adenine resulting in valine instead of glutamine in the sixth position of the Beta-globin molecule. Sickle cell disease results when this substitution occurs in a homozygous state. Other forms of sickle cell disease with variable severity can also occur when the heterozygote state is combined with a second variant Beta-globin chain such as hemoglobin C or Beta-thalassemia. Clinical manifestations result from polymerization of the abnormal hemoglobin and “sickling” of the red cells. The clinical manifestations most important to pediatric hospitalists include recurrent and chronic pain from dactylitis and vaso-occlusive crisis, acute chest syndrome, increased susceptibility to infections, aplastic crisis, splenic sequestration, stroke, acute hepatobiliary complications, and priapism. Pediatric hospitalists commonly encounter patients with known or suspected sickle cell disease and care for the various complications associated with the disease.

Pediatric hospitalists should be able to:

• Explain the impact of newborn screening on preventive care.
• Review the genetics and pathophysiology underlying the variants of sickle cell disease and their complications.
• Compare and contrast common sickle crisis presentations by age group.
• Describe the signs and symptoms of dactylitis, vaso-occlusive crisis, sepsis, acute chest syndrome, aplastic crisis, splenic sequestration, stroke, acute hepatobiliary complications, and priapism.
• Describe indications for hospital admission and escalation to intensive care.
• Identify the goals of inpatient therapy, attending to both acute and chronic needs.
• Distinguish patients with sickle cell disease presenting with fever who require inpatient management from those who can be safely managed in the outpatient setting.
• Recognize the unique considerations requiring expert consultation for patients with sickle cell disease undergoing surgical procedures.
• Summarize the roles of members of a comprehensive clinical care team, such as patients, the family/caregivers, subspecialty physicians, social worker, pharmacist, physical therapist, discharge planner, psychologist, and others.
• Discuss the therapeutic options available for complications of sickle cell disease, including the rationale for choosing a specific management plan.
• Discuss chronic complications of sickle cell disease, such as chronic pain, neurologic deficits with learning disabilities, hyposthenuria, delayed growth and development, psychosocial issues (including low self-esteem, anxiety, and depression), and others.
• Discuss the evidence-based guidelines for infection prevention, including vaccines and penicillin prophylaxis.
• Discuss medications for prevention and treatment of complications of sickle cell disease, including the use of hydroxyurea and L-glutamine.
• Explain the approach toward acute and chronic pain management, including the use of patient-controlled analgesia and timely transition to oral pain medications.
• Cite reasons for transfer to a referral center in cases requiring pediatric-specific services not available at the local facility.

Pediatric hospitalists should be able to:

• Diagnose sickle cell disease and its complications by performing an accurate history and physical examination, identifying cardinal features of the disease presentation and synthesizing information into unified assessment.
• Order appropriate laboratory and radiographic testing based on history and physical examination findings.
• Create a comprehensive evaluation and management plan, including the use of antimicrobial therapy, intravenous fluid hydration, pain management, transfusion therapy, and initiation of cardiovascular and pulmonary supportive care measures when appropriate.
• Identify patients with worsening status and respond with appropriate actions.
• Consult subspecialists in a timely manner when appropriate.
• Create a comprehensive discharge plan that includes clear home instructions, appropriate medications, and follow-up recommendations.

Pediatric hospitalists should be able to:

• Acknowledge the importance of effective communication and education with patients and the family/caregivers regarding the disease process, proposed therapies, expectations of inpatient therapy, and transition of care to the outpatient arena.
• Realize the psychosocial impact on the patient and family members/care givers.
• Recognize the value of collaboration with subspecialists and the primary care provider, to ensure coordinated longitudinal care for children with sickle cell disease.

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

• Collaborate with a multidisciplinary team consisting of subspecialty physicians, social workers, pharmacists, physical therapists, discharge planners, and psychologists to improve quality of care, increase patient satisfaction, and facilitate timely discharge from the acute care setting.
• Identify existing limitations for optimal care within the current hospital setting and work with hospital administration and community partners to develop and sustain appropriate referral systems and coordinated transfers of care.
• Lead, coordinate, or participate in the development of coordinated discharge plans and programs in the local community.

Introduction

Sickle cell disease is the most common autosomal recessive disease in African American individuals, occurring in 1 in 625 live births to African American couples. While it is most common in African Americans, sickle cell disease also occurs in individuals of Hispanic, Arabic, Native American, and Caucasian heritage. Sickle cell disease results from a single base-pair substitution of thymine for adenine resulting in valine instead of glutamine in the sixth position of the Beta-globin molecule. Sickle cell disease results when this substitution occurs in a homozygous state. Other forms of sickle cell disease with variable severity can also occur when the heterozygote state is combined with a second variant Beta-globin chain such as hemoglobin C or Beta-thalassemia. Clinical manifestations result from polymerization of the abnormal hemoglobin and “sickling” of the red cells. The clinical manifestations most important to pediatric hospitalists include recurrent and chronic pain from dactylitis and vaso-occlusive crisis, acute chest syndrome, increased susceptibility to infections, aplastic crisis, splenic sequestration, stroke, acute hepatobiliary complications, and priapism. Pediatric hospitalists commonly encounter patients with known or suspected sickle cell disease and care for the various complications associated with the disease.

Pediatric hospitalists should be able to:

• Explain the impact of newborn screening on preventive care.
• Review the genetics and pathophysiology underlying the variants of sickle cell disease and their complications.
• Compare and contrast common sickle crisis presentations by age group.
• Describe the signs and symptoms of dactylitis, vaso-occlusive crisis, sepsis, acute chest syndrome, aplastic crisis, splenic sequestration, stroke, acute hepatobiliary complications, and priapism.
• Describe indications for hospital admission and escalation to intensive care.
• Identify the goals of inpatient therapy, attending to both acute and chronic needs.
• Distinguish patients with sickle cell disease presenting with fever who require inpatient management from those who can be safely managed in the outpatient setting.
• Recognize the unique considerations requiring expert consultation for patients with sickle cell disease undergoing surgical procedures.
• Summarize the roles of members of a comprehensive clinical care team, such as patients, the family/caregivers, subspecialty physicians, social worker, pharmacist, physical therapist, discharge planner, psychologist, and others.
• Discuss the therapeutic options available for complications of sickle cell disease, including the rationale for choosing a specific management plan.
• Discuss chronic complications of sickle cell disease, such as chronic pain, neurologic deficits with learning disabilities, hyposthenuria, delayed growth and development, psychosocial issues (including low self-esteem, anxiety, and depression), and others.
• Discuss the evidence-based guidelines for infection prevention, including vaccines and penicillin prophylaxis.
• Discuss medications for prevention and treatment of complications of sickle cell disease, including the use of hydroxyurea and L-glutamine.
• Explain the approach toward acute and chronic pain management, including the use of patient-controlled analgesia and timely transition to oral pain medications.
• Cite reasons for transfer to a referral center in cases requiring pediatric-specific services not available at the local facility.

Pediatric hospitalists should be able to:

• Diagnose sickle cell disease and its complications by performing an accurate history and physical examination, identifying cardinal features of the disease presentation and synthesizing information into unified assessment.
• Order appropriate laboratory and radiographic testing based on history and physical examination findings.
• Create a comprehensive evaluation and management plan, including the use of antimicrobial therapy, intravenous fluid hydration, pain management, transfusion therapy, and initiation of cardiovascular and pulmonary supportive care measures when appropriate.
• Identify patients with worsening status and respond with appropriate actions.
• Consult subspecialists in a timely manner when appropriate.
• Create a comprehensive discharge plan that includes clear home instructions, appropriate medications, and follow-up recommendations.

Pediatric hospitalists should be able to:

• Acknowledge the importance of effective communication and education with patients and the family/caregivers regarding the disease process, proposed therapies, expectations of inpatient therapy, and transition of care to the outpatient arena.
• Realize the psychosocial impact on the patient and family members/care givers.
• Recognize the value of collaboration with subspecialists and the primary care provider, to ensure coordinated longitudinal care for children with sickle cell disease.

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

• Collaborate with a multidisciplinary team consisting of subspecialty physicians, social workers, pharmacists, physical therapists, discharge planners, and psychologists to improve quality of care, increase patient satisfaction, and facilitate timely discharge from the acute care setting.
• Identify existing limitations for optimal care within the current hospital setting and work with hospital administration and community partners to develop and sustain appropriate referral systems and coordinated transfers of care.
• Lead, coordinate, or participate in the development of coordinated discharge plans and programs in the local community.

Introduction

Early recognition and treatment of sepsis and shock is imperative to improve the outcomes of critically ill neonates and children. In adults, sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection. In children, the definition of sepsis focuses on the presence of systemic inflammatory response criteria in the context of suspected or proven infection. Early recognition of clinical findings associated with sepsis is necessary to appropriately intervene and prevent progression to shock. Shock can be categorized as distributive (as in sepsis), hypovolemic, cardiogenic, or obstructive. Ultimately, shock results from inadequate tissue perfusion to support metabolic demands, which may be caused by an inadequate supply of oxygen to the tissues or an increased demand of the tissues for oxygen. As a result, cellular hypoxia, anaerobic metabolism, and dysregulation result in irreversible cell damage and death. Pediatric hospitalists often encounter children with all forms of shock and should be adept at recognition and management to improve patient outcomes.

Pediatric hospitalists should be able to:

• Describe the components of tissue oxygen delivery, focusing on elements of the oxygen delivery equation, including cardiac output and oxygen content of the blood.
• Discuss the pathophysiology of tissue hypoxia, including hypoxemia, anemia, and ischemia.
• Identify vital sign and laboratory criteria that constitute sepsis in children.
• Discuss potential causes of sepsis, including bacterial, viral, fungal, parasitic, and rickettsial infections.
• Describe common diseases and conditions associated with the four forms of shock.
• Describe the role of empiric antibiotic therapy, including when antibiotics should be initiated and when to choose specific antibiotics and/or antivirals.
• Compare and contrast the presenting signs and symptoms of the four forms of shock, attending to differences in heart rate, blood pressure, pulses and peripheral perfusion, mental status, and urine output.
• Discuss compensatory mechanisms of early shock including increased heart rate, stroke volume, and vascular smooth muscle tone.
• List indications for chronotropic, inotropic, and blood pressure support, including the mechanisms of action for each class of medications.
• Identify the commonly performed diagnostic studies (such as laboratory, radiographic, and others) which aid in determining the extent or form of shock, including venous lactate, mixed venous saturation, urine output, chest radiograph, and others.
• Summarize the approach toward stabilization of each form of shock.

Pediatric hospitalists should be able to:

• Perform an initial rapid assessment using Pediatric Advanced Life Support skills.
• Identify early signs of sepsis and shock from a focused history, physical examination, and initial diagnostic studies.
• Initiate appropriate and timely interventions based on the form of shock.
• Order and correctly interpret results of common studies to determine the cause of sepsis and extent of shock, such as complete blood count, chemistries, blood gas, venous lactate, mixed venous saturation, radiographs, and others.
• Select the appropriate empiric antibiotic regimen.
• Order appropriate monitoring and correctly interpret monitoring data.
• Identify cardiomegaly and other signs of congestive heart failure on physical exam and chest radiograph.
• Facilitate effective transfer to a tertiary care center or intensive care setting when appropriate.

Pediatric hospitalists should be able to:

• Realize the importance of effective communication with emergency room and intensive care staff to assign the appropriate level of care for patients with sepsis and shock.
• Acknowledge the value of listening effectively and responding to concerns of the family/caregivers and healthcare providers regarding changes in physiologic parameters, including vital signs, mental status, physical examination, and urine output.
• Recognize the value of providing support and education to the family/caregivers on the nuances and complexities of the various forms of shock and the importance of careful monitoring and evaluation.

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

• Work with hospital administration, staff, subspecialists, and other services to educate healthcare providers on the importance of early recognition of sepsis and shock to prevent complications, including end-organ failure and death.
• Lead, coordinate, or participate in educational programs, including those involving simulation, to acquire the skills needed for appropriate recognition and intervention for children in sepsis and shock.
• Lead, coordinate, or participate in the development and implementation of trigger tools and rapid response systems to assist in recognition and stabilization of sepsis and early shock.
• Lead, coordinate, or participate in the design and implementation of performance bundles for best practice, sustainability, and performance improvement around the care provided to patients with sepsis and shock.
• Collaborate with hospital administration and community partners to develop and sustain local American Heart Association Pediatric Basic and Advanced Life Support classes for providers, community members, and other stakeholders.

Introduction

Early recognition and treatment of sepsis and shock is imperative to improve the outcomes of critically ill neonates and children. In adults, sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection. In children, the definition of sepsis focuses on the presence of systemic inflammatory response criteria in the context of suspected or proven infection. Early recognition of clinical findings associated with sepsis is necessary to appropriately intervene and prevent progression to shock. Shock can be categorized as distributive (as in sepsis), hypovolemic, cardiogenic, or obstructive. Ultimately, shock results from inadequate tissue perfusion to support metabolic demands, which may be caused by an inadequate supply of oxygen to the tissues or an increased demand of the tissues for oxygen. As a result, cellular hypoxia, anaerobic metabolism, and dysregulation result in irreversible cell damage and death. Pediatric hospitalists often encounter children with all forms of shock and should be adept at recognition and management to improve patient outcomes.

Pediatric hospitalists should be able to:

• Describe the components of tissue oxygen delivery, focusing on elements of the oxygen delivery equation, including cardiac output and oxygen content of the blood.
• Discuss the pathophysiology of tissue hypoxia, including hypoxemia, anemia, and ischemia.
• Identify vital sign and laboratory criteria that constitute sepsis in children.
• Discuss potential causes of sepsis, including bacterial, viral, fungal, parasitic, and rickettsial infections.
• Describe common diseases and conditions associated with the four forms of shock.
• Describe the role of empiric antibiotic therapy, including when antibiotics should be initiated and when to choose specific antibiotics and/or antivirals.
• Compare and contrast the presenting signs and symptoms of the four forms of shock, attending to differences in heart rate, blood pressure, pulses and peripheral perfusion, mental status, and urine output.
• Discuss compensatory mechanisms of early shock including increased heart rate, stroke volume, and vascular smooth muscle tone.
• List indications for chronotropic, inotropic, and blood pressure support, including the mechanisms of action for each class of medications.
• Identify the commonly performed diagnostic studies (such as laboratory, radiographic, and others) which aid in determining the extent or form of shock, including venous lactate, mixed venous saturation, urine output, chest radiograph, and others.
• Summarize the approach toward stabilization of each form of shock.

Pediatric hospitalists should be able to:

• Perform an initial rapid assessment using Pediatric Advanced Life Support skills.
• Identify early signs of sepsis and shock from a focused history, physical examination, and initial diagnostic studies.
• Initiate appropriate and timely interventions based on the form of shock.
• Order and correctly interpret results of common studies to determine the cause of sepsis and extent of shock, such as complete blood count, chemistries, blood gas, venous lactate, mixed venous saturation, radiographs, and others.
• Select the appropriate empiric antibiotic regimen.
• Order appropriate monitoring and correctly interpret monitoring data.
• Identify cardiomegaly and other signs of congestive heart failure on physical exam and chest radiograph.
• Facilitate effective transfer to a tertiary care center or intensive care setting when appropriate.

Pediatric hospitalists should be able to:

• Realize the importance of effective communication with emergency room and intensive care staff to assign the appropriate level of care for patients with sepsis and shock.
• Acknowledge the value of listening effectively and responding to concerns of the family/caregivers and healthcare providers regarding changes in physiologic parameters, including vital signs, mental status, physical examination, and urine output.
• Recognize the value of providing support and education to the family/caregivers on the nuances and complexities of the various forms of shock and the importance of careful monitoring and evaluation.

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

• Work with hospital administration, staff, subspecialists, and other services to educate healthcare providers on the importance of early recognition of sepsis and shock to prevent complications, including end-organ failure and death.
• Lead, coordinate, or participate in educational programs, including those involving simulation, to acquire the skills needed for appropriate recognition and intervention for children in sepsis and shock.
• Lead, coordinate, or participate in the development and implementation of trigger tools and rapid response systems to assist in recognition and stabilization of sepsis and early shock.
• Lead, coordinate, or participate in the design and implementation of performance bundles for best practice, sustainability, and performance improvement around the care provided to patients with sepsis and shock.
• Collaborate with hospital administration and community partners to develop and sustain local American Heart Association Pediatric Basic and Advanced Life Support classes for providers, community members, and other stakeholders.

Introduction

Early recognition and treatment of sepsis and shock is imperative to improve the outcomes of critically ill neonates and children. In adults, sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection. In children, the definition of sepsis focuses on the presence of systemic inflammatory response criteria in the context of suspected or proven infection. Early recognition of clinical findings associated with sepsis is necessary to appropriately intervene and prevent progression to shock. Shock can be categorized as distributive (as in sepsis), hypovolemic, cardiogenic, or obstructive. Ultimately, shock results from inadequate tissue perfusion to support metabolic demands, which may be caused by an inadequate supply of oxygen to the tissues or an increased demand of the tissues for oxygen. As a result, cellular hypoxia, anaerobic metabolism, and dysregulation result in irreversible cell damage and death. Pediatric hospitalists often encounter children with all forms of shock and should be adept at recognition and management to improve patient outcomes.

Pediatric hospitalists should be able to:

• Describe the components of tissue oxygen delivery, focusing on elements of the oxygen delivery equation, including cardiac output and oxygen content of the blood.
• Discuss the pathophysiology of tissue hypoxia, including hypoxemia, anemia, and ischemia.
• Identify vital sign and laboratory criteria that constitute sepsis in children.
• Discuss potential causes of sepsis, including bacterial, viral, fungal, parasitic, and rickettsial infections.
• Describe common diseases and conditions associated with the four forms of shock.
• Describe the role of empiric antibiotic therapy, including when antibiotics should be initiated and when to choose specific antibiotics and/or antivirals.
• Compare and contrast the presenting signs and symptoms of the four forms of shock, attending to differences in heart rate, blood pressure, pulses and peripheral perfusion, mental status, and urine output.
• Discuss compensatory mechanisms of early shock including increased heart rate, stroke volume, and vascular smooth muscle tone.
• List indications for chronotropic, inotropic, and blood pressure support, including the mechanisms of action for each class of medications.
• Identify the commonly performed diagnostic studies (such as laboratory, radiographic, and others) which aid in determining the extent or form of shock, including venous lactate, mixed venous saturation, urine output, chest radiograph, and others.
• Summarize the approach toward stabilization of each form of shock.

Pediatric hospitalists should be able to:

• Perform an initial rapid assessment using Pediatric Advanced Life Support skills.
• Identify early signs of sepsis and shock from a focused history, physical examination, and initial diagnostic studies.
• Initiate appropriate and timely interventions based on the form of shock.
• Order and correctly interpret results of common studies to determine the cause of sepsis and extent of shock, such as complete blood count, chemistries, blood gas, venous lactate, mixed venous saturation, radiographs, and others.
• Select the appropriate empiric antibiotic regimen.
• Order appropriate monitoring and correctly interpret monitoring data.
• Identify cardiomegaly and other signs of congestive heart failure on physical exam and chest radiograph.
• Facilitate effective transfer to a tertiary care center or intensive care setting when appropriate.

Pediatric hospitalists should be able to:

• Realize the importance of effective communication with emergency room and intensive care staff to assign the appropriate level of care for patients with sepsis and shock.
• Acknowledge the value of listening effectively and responding to concerns of the family/caregivers and healthcare providers regarding changes in physiologic parameters, including vital signs, mental status, physical examination, and urine output.
• Recognize the value of providing support and education to the family/caregivers on the nuances and complexities of the various forms of shock and the importance of careful monitoring and evaluation.

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

• Work with hospital administration, staff, subspecialists, and other services to educate healthcare providers on the importance of early recognition of sepsis and shock to prevent complications, including end-organ failure and death.
• Lead, coordinate, or participate in educational programs, including those involving simulation, to acquire the skills needed for appropriate recognition and intervention for children in sepsis and shock.
• Lead, coordinate, or participate in the development and implementation of trigger tools and rapid response systems to assist in recognition and stabilization of sepsis and early shock.
• Lead, coordinate, or participate in the design and implementation of performance bundles for best practice, sustainability, and performance improvement around the care provided to patients with sepsis and shock.
• Collaborate with hospital administration and community partners to develop and sustain local American Heart Association Pediatric Basic and Advanced Life Support classes for providers, community members, and other stakeholders.