Lumbar puncture is a procedure during which a needle is inserted into the subarachnoid space to obtain cerebrospinal fluid (CSF) for laboratory analysis. CSF is formed within the ventricular choroid plexus and distributed in the ventricular system, basal cisterns and the subarachnoid space. The Healthcare Cost and Utilization Project (HCUP) estimates over 240,000 lumbar punctures were performed in hospitalized patients in 2002. Hospitalists identify patients who require lumbar puncture to assess acute or chronic central nervous system (CNS) disease processes. Early diagnosis and therapy of acute CNS infections or subarachnoid hemorrhage is essential to lower morbidity and mortality.

KNOWLEDGE

Hospitalists should be able to:

• Describe the anatomy of the spinal column and the spinal cord.

• Describe the signs and symptoms that require lumbar puncture.

• Describe disease processes that require frequent therapeutic lumbar puncture.

• Explain the indications and contraindications for lumbar puncture, including potential risks and complications.

• Describe the physical examination maneuvers used in the evaluation of suspected CNS infections and identify their sensitivity and specificity.

• List the indications for brain imaging prior to lumbar puncture.

• Explain the diagnostic testing indicated for CSF based on the clinical presentation.

• Describe indications for the use of interventional radiology in performing lumber puncture.

• Select the necessary equipment to perform a lumbar puncture at the bedside.

SKILLS

Hospitalists should be able to:

• Elicit a thorough history and review medical records to identify indications and potential contraindications for lumbar puncture.

• Perform a thorough physical examination, including neurologic and fundoscopic examination.

• Properly position the patient for lumbar puncture and identify major anatomic landmarks.

• Use sterile techniques during preparation for and performance of lumbar puncture.

• Obtain an accurate measurement of and interpret the opening pressure.

• Maintain clinician safety with appropriate protective wear.

• Manage the complications of lumbar puncture, particularly post‐lumbar puncture headache.

• Order and interpret indicated diagnostic tests for CSF fluid.

• Order and interpret platelet and coagulation studies when indicated.

• Synthesize data obtained from history, physical examination, radiographic imaging, and CSF analysis to develop an evidence based treatment plan.

ATTITUDES

Hospitalists should be able to:

• Communicate with patients and families to explain the procedure, its expected diagnostic benefits, and potential complications; and to obtain informed consent.

• Discuss with patients and families pain management strategies for discomfort during and after lumbar puncture.

• Recognize the importance of proper positioning following the procedure.

• Identify patients who require isolation precautions.

• Manage patient discomfort or pain during and after the procedure.

• Recognize the indications for specialty consultation, which may include interventional radiology, infectious disease or neurology.

SYSTEM ORGANIZATION AND IMPROVEMENT

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

• Collaborate with emergency physicians to develop protocols for rapid identification and evaluation of patients with suspected CNS infections.

• Lead, coordinate or participate in efforts to develop strategies to minimize institution complication rates.

• Lead, coordinate or participate in quality improvement programs to monitor hospitalists' performance and/or supervision of lumbar puncture.

• Lead, coordinate or participate in efforts to organize and consolidate lumbar puncture equipment in an identifiable location in the hospital, easily accessible to clinicians who perform the procedure.

Lumbar puncture is a procedure during which a needle is inserted into the subarachnoid space to obtain cerebrospinal fluid (CSF) for laboratory analysis. CSF is formed within the ventricular choroid plexus and distributed in the ventricular system, basal cisterns and the subarachnoid space. The Healthcare Cost and Utilization Project (HCUP) estimates over 240,000 lumbar punctures were performed in hospitalized patients in 2002. Hospitalists identify patients who require lumbar puncture to assess acute or chronic central nervous system (CNS) disease processes. Early diagnosis and therapy of acute CNS infections or subarachnoid hemorrhage is essential to lower morbidity and mortality.

KNOWLEDGE

Hospitalists should be able to:

• Describe the anatomy of the spinal column and the spinal cord.

• Describe the signs and symptoms that require lumbar puncture.

• Describe disease processes that require frequent therapeutic lumbar puncture.

• Explain the indications and contraindications for lumbar puncture, including potential risks and complications.

• Describe the physical examination maneuvers used in the evaluation of suspected CNS infections and identify their sensitivity and specificity.

• List the indications for brain imaging prior to lumbar puncture.

• Explain the diagnostic testing indicated for CSF based on the clinical presentation.

• Describe indications for the use of interventional radiology in performing lumber puncture.

• Select the necessary equipment to perform a lumbar puncture at the bedside.

SKILLS

Hospitalists should be able to:

• Elicit a thorough history and review medical records to identify indications and potential contraindications for lumbar puncture.

• Perform a thorough physical examination, including neurologic and fundoscopic examination.

• Properly position the patient for lumbar puncture and identify major anatomic landmarks.

• Use sterile techniques during preparation for and performance of lumbar puncture.

• Obtain an accurate measurement of and interpret the opening pressure.

• Maintain clinician safety with appropriate protective wear.

• Manage the complications of lumbar puncture, particularly post‐lumbar puncture headache.

• Order and interpret indicated diagnostic tests for CSF fluid.

• Order and interpret platelet and coagulation studies when indicated.

• Synthesize data obtained from history, physical examination, radiographic imaging, and CSF analysis to develop an evidence based treatment plan.

ATTITUDES

Hospitalists should be able to:

• Communicate with patients and families to explain the procedure, its expected diagnostic benefits, and potential complications; and to obtain informed consent.

• Discuss with patients and families pain management strategies for discomfort during and after lumbar puncture.

• Recognize the importance of proper positioning following the procedure.

• Identify patients who require isolation precautions.

• Manage patient discomfort or pain during and after the procedure.

• Recognize the indications for specialty consultation, which may include interventional radiology, infectious disease or neurology.

SYSTEM ORGANIZATION AND IMPROVEMENT

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

• Collaborate with emergency physicians to develop protocols for rapid identification and evaluation of patients with suspected CNS infections.

• Lead, coordinate or participate in efforts to develop strategies to minimize institution complication rates.

• Lead, coordinate or participate in quality improvement programs to monitor hospitalists' performance and/or supervision of lumbar puncture.

• Lead, coordinate or participate in efforts to organize and consolidate lumbar puncture equipment in an identifiable location in the hospital, easily accessible to clinicians who perform the procedure.

Lumbar puncture is a procedure during which a needle is inserted into the subarachnoid space to obtain cerebrospinal fluid (CSF) for laboratory analysis. CSF is formed within the ventricular choroid plexus and distributed in the ventricular system, basal cisterns and the subarachnoid space. The Healthcare Cost and Utilization Project (HCUP) estimates over 240,000 lumbar punctures were performed in hospitalized patients in 2002. Hospitalists identify patients who require lumbar puncture to assess acute or chronic central nervous system (CNS) disease processes. Early diagnosis and therapy of acute CNS infections or subarachnoid hemorrhage is essential to lower morbidity and mortality.

KNOWLEDGE

Hospitalists should be able to:

• Describe the anatomy of the spinal column and the spinal cord.

• Describe the signs and symptoms that require lumbar puncture.

• Describe disease processes that require frequent therapeutic lumbar puncture.

• Explain the indications and contraindications for lumbar puncture, including potential risks and complications.

• Describe the physical examination maneuvers used in the evaluation of suspected CNS infections and identify their sensitivity and specificity.

• List the indications for brain imaging prior to lumbar puncture.

• Explain the diagnostic testing indicated for CSF based on the clinical presentation.

• Describe indications for the use of interventional radiology in performing lumber puncture.

• Select the necessary equipment to perform a lumbar puncture at the bedside.

SKILLS

Hospitalists should be able to:

• Elicit a thorough history and review medical records to identify indications and potential contraindications for lumbar puncture.

• Perform a thorough physical examination, including neurologic and fundoscopic examination.

• Properly position the patient for lumbar puncture and identify major anatomic landmarks.

• Use sterile techniques during preparation for and performance of lumbar puncture.

• Obtain an accurate measurement of and interpret the opening pressure.

• Maintain clinician safety with appropriate protective wear.

• Manage the complications of lumbar puncture, particularly post‐lumbar puncture headache.

• Order and interpret indicated diagnostic tests for CSF fluid.

• Order and interpret platelet and coagulation studies when indicated.

• Synthesize data obtained from history, physical examination, radiographic imaging, and CSF analysis to develop an evidence based treatment plan.

ATTITUDES

Hospitalists should be able to:

• Communicate with patients and families to explain the procedure, its expected diagnostic benefits, and potential complications; and to obtain informed consent.

• Discuss with patients and families pain management strategies for discomfort during and after lumbar puncture.

• Recognize the importance of proper positioning following the procedure.

• Identify patients who require isolation precautions.

• Manage patient discomfort or pain during and after the procedure.

• Recognize the indications for specialty consultation, which may include interventional radiology, infectious disease or neurology.

SYSTEM ORGANIZATION AND IMPROVEMENT

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

• Collaborate with emergency physicians to develop protocols for rapid identification and evaluation of patients with suspected CNS infections.

• Lead, coordinate or participate in efforts to develop strategies to minimize institution complication rates.

• Lead, coordinate or participate in quality improvement programs to monitor hospitalists' performance and/or supervision of lumbar puncture.

• Lead, coordinate or participate in efforts to organize and consolidate lumbar puncture equipment in an identifiable location in the hospital, easily accessible to clinicians who perform the procedure.

Communication refers the transfer of information between individuals, groups, or organizations. Hospitalists communicate in multiple modalities with patients, families, other health care providers and administrators. Patient‐centered care requires that physicians and members of multidisciplinary teams effectively inform, educate, reassure, and empower patients and families to participate in the creation of a care plan. Effective communication is central to the role of the hospitalist to promote efficient, safe, and high quality care and to reduce discontinuity of care. Hospitalists can lead initiatives to improve communication amongst team members, patients, families, primary care physicians and receiving physicians within the hospital and at extended care facilities beginning with admission and through all care transitions.

KNOWLEDGE

Hospitalists should be able to:

• Describe key elements in a message.

• Describe various modalities used to communicate, including advantages and disadvantages of each.

• Describe techniques of providing and eliciting feedback, and differentiate formative and summative feedback.

• Define the role of effective communication in risk management.

SKILLS

Hospitalists should be able to:

• Explain issues of pathophysiology, treatment options, and prognosis using language understandable to patients, family members, and other care providers.

• Listen without interruption to the questions and concerns of patients, family members and other care providers, and promptly address any issues.

• Identify potentially problematic family and team dynamics and explore their effects on the patient.

• Identify a family spokesperson.

• Facilitate family meetings when necessary, collaborating with nurses and other team members to identify goals for the meeting, summarize conclusions reached, and utilize support staff as needed.

• Effectively utilize a translator when communicating with patients and families speaking a different language.

ATTITUDES

Hospitalists should be able to:

• Appreciate the positive impact that subtle changes in body language, such as sitting and appropriate touching, have on patient and family perceptions of an interaction.

• Demonstrate empathy for patient and family concerns.

• Recognize the importance of allowing patients and families to have questions answered in a straightforward and timely manner.

• Demonstrate cultural sensitivity in all interactions with patients and families.

• Appreciate the importance of active listening.

• Counsel patients and families objectively when considering various treatment options.

• Acknowledge and remain comfortable with uncertainty in issues of prognosis.

• Provide a quiet and comfortable setting for family meetings.

• Discuss the patient's illness realistically without negating hope.

• Ensure that input from surrogate decision makers accurately reflects the patient's interests, with a minimum of personal bias.

• Communicate with nursing staff and consultants on a regular basis to convey critical information.

• Remain available to the patient and family for follow‐up questions through all care transitions.

• Lead, coordinate or participate in hospital initiatives to assure adequate translator services and cross cultural sensitivities.

Communication refers the transfer of information between individuals, groups, or organizations. Hospitalists communicate in multiple modalities with patients, families, other health care providers and administrators. Patient‐centered care requires that physicians and members of multidisciplinary teams effectively inform, educate, reassure, and empower patients and families to participate in the creation of a care plan. Effective communication is central to the role of the hospitalist to promote efficient, safe, and high quality care and to reduce discontinuity of care. Hospitalists can lead initiatives to improve communication amongst team members, patients, families, primary care physicians and receiving physicians within the hospital and at extended care facilities beginning with admission and through all care transitions.

KNOWLEDGE

Hospitalists should be able to:

• Describe key elements in a message.

• Describe various modalities used to communicate, including advantages and disadvantages of each.

• Describe techniques of providing and eliciting feedback, and differentiate formative and summative feedback.

• Define the role of effective communication in risk management.

SKILLS

Hospitalists should be able to:

• Explain issues of pathophysiology, treatment options, and prognosis using language understandable to patients, family members, and other care providers.

• Listen without interruption to the questions and concerns of patients, family members and other care providers, and promptly address any issues.

• Identify potentially problematic family and team dynamics and explore their effects on the patient.

• Identify a family spokesperson.

• Facilitate family meetings when necessary, collaborating with nurses and other team members to identify goals for the meeting, summarize conclusions reached, and utilize support staff as needed.

• Effectively utilize a translator when communicating with patients and families speaking a different language.

ATTITUDES

Hospitalists should be able to:

• Appreciate the positive impact that subtle changes in body language, such as sitting and appropriate touching, have on patient and family perceptions of an interaction.

• Demonstrate empathy for patient and family concerns.

• Recognize the importance of allowing patients and families to have questions answered in a straightforward and timely manner.

• Demonstrate cultural sensitivity in all interactions with patients and families.

• Appreciate the importance of active listening.

• Counsel patients and families objectively when considering various treatment options.

• Acknowledge and remain comfortable with uncertainty in issues of prognosis.

• Provide a quiet and comfortable setting for family meetings.

• Discuss the patient's illness realistically without negating hope.

• Ensure that input from surrogate decision makers accurately reflects the patient's interests, with a minimum of personal bias.

• Communicate with nursing staff and consultants on a regular basis to convey critical information.

• Remain available to the patient and family for follow‐up questions through all care transitions.

• Lead, coordinate or participate in hospital initiatives to assure adequate translator services and cross cultural sensitivities.

Communication refers the transfer of information between individuals, groups, or organizations. Hospitalists communicate in multiple modalities with patients, families, other health care providers and administrators. Patient‐centered care requires that physicians and members of multidisciplinary teams effectively inform, educate, reassure, and empower patients and families to participate in the creation of a care plan. Effective communication is central to the role of the hospitalist to promote efficient, safe, and high quality care and to reduce discontinuity of care. Hospitalists can lead initiatives to improve communication amongst team members, patients, families, primary care physicians and receiving physicians within the hospital and at extended care facilities beginning with admission and through all care transitions.

KNOWLEDGE

Hospitalists should be able to:

• Describe key elements in a message.

• Describe various modalities used to communicate, including advantages and disadvantages of each.

• Describe techniques of providing and eliciting feedback, and differentiate formative and summative feedback.

• Define the role of effective communication in risk management.

SKILLS

Hospitalists should be able to:

• Explain issues of pathophysiology, treatment options, and prognosis using language understandable to patients, family members, and other care providers.

• Listen without interruption to the questions and concerns of patients, family members and other care providers, and promptly address any issues.

• Identify potentially problematic family and team dynamics and explore their effects on the patient.

• Identify a family spokesperson.

• Facilitate family meetings when necessary, collaborating with nurses and other team members to identify goals for the meeting, summarize conclusions reached, and utilize support staff as needed.

• Effectively utilize a translator when communicating with patients and families speaking a different language.

ATTITUDES

Hospitalists should be able to:

• Appreciate the positive impact that subtle changes in body language, such as sitting and appropriate touching, have on patient and family perceptions of an interaction.

• Demonstrate empathy for patient and family concerns.

• Recognize the importance of allowing patients and families to have questions answered in a straightforward and timely manner.

• Demonstrate cultural sensitivity in all interactions with patients and families.

• Appreciate the importance of active listening.

• Counsel patients and families objectively when considering various treatment options.

• Acknowledge and remain comfortable with uncertainty in issues of prognosis.

• Provide a quiet and comfortable setting for family meetings.

• Discuss the patient's illness realistically without negating hope.

• Ensure that input from surrogate decision makers accurately reflects the patient's interests, with a minimum of personal bias.

• Communicate with nursing staff and consultants on a regular basis to convey critical information.

• Remain available to the patient and family for follow‐up questions through all care transitions.

• Lead, coordinate or participate in hospital initiatives to assure adequate translator services and cross cultural sensitivities.

Urinary tract infection (UTI) refers to a spectrum of clinical presentations ranging from asymptomatic urinary infection to acute pyelonephritis with septicemia. UTI is a common infection diagnosed at the time of admission or acquired during hospitalization. According to the Healthcare Cost and Utilization Project (HCUP), the Diagnosis Related Group for UTI with complications or co‐morbidities accounted for almost 302,000 hospital discharges in 2002. The mean length‐of‐stay was 4.9 days with mean charges of $13,000 per patient. In‐hospital mortality was 2.2% for this group. Hospitalists diagnose, treat and identify complications of UTI. Hospitalists can lead hospital‐wide patient safety initiatives to reduce the incidence of hospital‐acquired infection and emerging antibiotic resistance.

KNOWLEDGE

Hospitalists should be able to:

• Define UTI and describe the pathophysiology that leads to complicated UTI.

• Describe common symptoms and signs of UTI.

• Explain the clinical spectrum of UTI including patient populations that may present with atypical symptoms.

• Name common community‐acquired and hospital‐acquired urinary pathogens.

• Explain how local and national resistance patterns impact the selection of initial antibiotics.

• Distinguish UTI from sterile pyuria and from colonization.

• Explain the indications and limitations of specific tests used to diagnose UTI, its underlying causes and complicating conditions.

• Define risk factors for UTI.

• Name specific patient populations at increased risk for development of hospital acquired or other complicated UTIs.

• Distinguish the specific clinical management, including antibiotic selection for different patient populations, including patients with community‐acquired UTI, hospital‐acquired UTI, chronic indwelling catheters, pregnancy, immunosuppression and incidentally recognized UTI.

• Explain the indications for hospitalization.

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

SKILLS

Hospitalists should be able to:

• Elicit a targeted history to identify risk factors and symptoms for UTI and its known complications.

• Perform a focused physical examination looking for signs of complicated UTI, prostatitis and other co‐morbid conditions.

• Order and interpret urinalysis and urine culture.

• Order and interpret the results of imaging studies when indicated.

• Formulate an initial care plan based on patient risk factors, acute medical illness, co‐morbid disease, and local and national antibiotic resistance patterns.

• Adjust antibiotic therapy based on subsequent culture results and determine appropriate duration of treatment.

• Recognize and address complications of UTI and/or inadequate response to therapy.

• Evaluate and treat patients for UTI in the perioperative setting when indicated.

ATTITUDES

Hospitalists should be able to:

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

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

• Recognize indications for specialty consultation, which may include urology or infectious disease services.

• Promote and employ prevention measures, which may include early removal of urinary catheters and other interventions to prevent recurrent UTI.

• Apply judicious antibiotic selection to help reduce antibiotic resistance.

• Employ a multidisciplinary approach to the care of patients with complicated UTI that begins on admission and continues through all care transitions.

• Appreciate and treat patient's pain.

• Document treatment plan, and provide clear discharge instructions for the receiving primary care physician, including duration of antibiotic treatment and need for follow‐up testing.

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

• Coordinate discharge plans when patients will require ongoing skilled nursing care.

• Utilize evidence based recommendations for the diagnosis and treatment of UTI.

SYSTEM ORGANIZATION AND IMPROVEMENT

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

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

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

• Lead, coordinate or participate in multidisciplinary initiatives to minimize use and duration of urinary catheters and reduce incidence of hospital‐acquired UTI.

Urinary tract infection (UTI) refers to a spectrum of clinical presentations ranging from asymptomatic urinary infection to acute pyelonephritis with septicemia. UTI is a common infection diagnosed at the time of admission or acquired during hospitalization. According to the Healthcare Cost and Utilization Project (HCUP), the Diagnosis Related Group for UTI with complications or co‐morbidities accounted for almost 302,000 hospital discharges in 2002. The mean length‐of‐stay was 4.9 days with mean charges of $13,000 per patient. In‐hospital mortality was 2.2% for this group. Hospitalists diagnose, treat and identify complications of UTI. Hospitalists can lead hospital‐wide patient safety initiatives to reduce the incidence of hospital‐acquired infection and emerging antibiotic resistance.

KNOWLEDGE

Hospitalists should be able to:

• Define UTI and describe the pathophysiology that leads to complicated UTI.

• Describe common symptoms and signs of UTI.

• Explain the clinical spectrum of UTI including patient populations that may present with atypical symptoms.

• Name common community‐acquired and hospital‐acquired urinary pathogens.

• Explain how local and national resistance patterns impact the selection of initial antibiotics.

• Distinguish UTI from sterile pyuria and from colonization.

• Explain the indications and limitations of specific tests used to diagnose UTI, its underlying causes and complicating conditions.

• Define risk factors for UTI.

• Name specific patient populations at increased risk for development of hospital acquired or other complicated UTIs.

• Distinguish the specific clinical management, including antibiotic selection for different patient populations, including patients with community‐acquired UTI, hospital‐acquired UTI, chronic indwelling catheters, pregnancy, immunosuppression and incidentally recognized UTI.

• Explain the indications for hospitalization.

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

SKILLS

Hospitalists should be able to:

• Elicit a targeted history to identify risk factors and symptoms for UTI and its known complications.

• Perform a focused physical examination looking for signs of complicated UTI, prostatitis and other co‐morbid conditions.

• Order and interpret urinalysis and urine culture.

• Order and interpret the results of imaging studies when indicated.

• Formulate an initial care plan based on patient risk factors, acute medical illness, co‐morbid disease, and local and national antibiotic resistance patterns.

• Adjust antibiotic therapy based on subsequent culture results and determine appropriate duration of treatment.

• Recognize and address complications of UTI and/or inadequate response to therapy.

• Evaluate and treat patients for UTI in the perioperative setting when indicated.

ATTITUDES

Hospitalists should be able to:

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

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

• Recognize indications for specialty consultation, which may include urology or infectious disease services.

• Promote and employ prevention measures, which may include early removal of urinary catheters and other interventions to prevent recurrent UTI.

• Apply judicious antibiotic selection to help reduce antibiotic resistance.

• Employ a multidisciplinary approach to the care of patients with complicated UTI that begins on admission and continues through all care transitions.

• Appreciate and treat patient's pain.

• Document treatment plan, and provide clear discharge instructions for the receiving primary care physician, including duration of antibiotic treatment and need for follow‐up testing.

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

• Coordinate discharge plans when patients will require ongoing skilled nursing care.

• Utilize evidence based recommendations for the diagnosis and treatment of UTI.

SYSTEM ORGANIZATION AND IMPROVEMENT

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

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

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

• Lead, coordinate or participate in multidisciplinary initiatives to minimize use and duration of urinary catheters and reduce incidence of hospital‐acquired UTI.

Urinary tract infection (UTI) refers to a spectrum of clinical presentations ranging from asymptomatic urinary infection to acute pyelonephritis with septicemia. UTI is a common infection diagnosed at the time of admission or acquired during hospitalization. According to the Healthcare Cost and Utilization Project (HCUP), the Diagnosis Related Group for UTI with complications or co‐morbidities accounted for almost 302,000 hospital discharges in 2002. The mean length‐of‐stay was 4.9 days with mean charges of $13,000 per patient. In‐hospital mortality was 2.2% for this group. Hospitalists diagnose, treat and identify complications of UTI. Hospitalists can lead hospital‐wide patient safety initiatives to reduce the incidence of hospital‐acquired infection and emerging antibiotic resistance.

KNOWLEDGE

Hospitalists should be able to:

• Define UTI and describe the pathophysiology that leads to complicated UTI.

• Describe common symptoms and signs of UTI.

• Explain the clinical spectrum of UTI including patient populations that may present with atypical symptoms.

• Name common community‐acquired and hospital‐acquired urinary pathogens.

• Explain how local and national resistance patterns impact the selection of initial antibiotics.

• Distinguish UTI from sterile pyuria and from colonization.

• Explain the indications and limitations of specific tests used to diagnose UTI, its underlying causes and complicating conditions.

• Define risk factors for UTI.

• Name specific patient populations at increased risk for development of hospital acquired or other complicated UTIs.

• Distinguish the specific clinical management, including antibiotic selection for different patient populations, including patients with community‐acquired UTI, hospital‐acquired UTI, chronic indwelling catheters, pregnancy, immunosuppression and incidentally recognized UTI.

• Explain the indications for hospitalization.

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

SKILLS

Hospitalists should be able to:

• Elicit a targeted history to identify risk factors and symptoms for UTI and its known complications.

• Perform a focused physical examination looking for signs of complicated UTI, prostatitis and other co‐morbid conditions.

• Order and interpret urinalysis and urine culture.

• Order and interpret the results of imaging studies when indicated.

• Formulate an initial care plan based on patient risk factors, acute medical illness, co‐morbid disease, and local and national antibiotic resistance patterns.

• Adjust antibiotic therapy based on subsequent culture results and determine appropriate duration of treatment.

• Recognize and address complications of UTI and/or inadequate response to therapy.

• Evaluate and treat patients for UTI in the perioperative setting when indicated.

ATTITUDES

Hospitalists should be able to:

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

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

• Recognize indications for specialty consultation, which may include urology or infectious disease services.

• Promote and employ prevention measures, which may include early removal of urinary catheters and other interventions to prevent recurrent UTI.

• Apply judicious antibiotic selection to help reduce antibiotic resistance.

• Employ a multidisciplinary approach to the care of patients with complicated UTI that begins on admission and continues through all care transitions.

• Appreciate and treat patient's pain.

• Document treatment plan, and provide clear discharge instructions for the receiving primary care physician, including duration of antibiotic treatment and need for follow‐up testing.

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

• Coordinate discharge plans when patients will require ongoing skilled nursing care.

• Utilize evidence based recommendations for the diagnosis and treatment of UTI.

SYSTEM ORGANIZATION AND IMPROVEMENT

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

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

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

• Lead, coordinate or participate in multidisciplinary initiatives to minimize use and duration of urinary catheters and reduce incidence of hospital‐acquired UTI.

The Institute of Medicine has defined patient centered care as one of the six aims for healthcare improvements in the 21^st century. Patient centered care requires that physicians and members of multidisciplinary teams effectively inform, educate, reassure and empower patients and families to participate in the creation and implementation of a care plan. Patient safety initiatives focus on the role of patient education in improving the quality of care from the perspective of both patients and clinicians. Hospitalists can develop and promote strategies to improve patient education initiatives and foster greater patient and family involvement in health care decisions and management.

KNOWLEDGE

Hospitalists should be able to:

• Describe the guiding principles for patient education.

• Explain the factors that impact the success or failure of behavior change strategies.

• Identify institutional resources for patient education materials and programs.

• Summarize the evidence for the primacy of patient education as a means to improve the quality of health care.

• Discuss the contextual factors that influence a patient's readiness to learn new information.

• Describe the role of patient education in the management of chronic diseases, which may include diabetes, congestive heart failure, and asthma.

• Explain how each patient's socio‐cultural background affects his or her health beliefs and behavior.

• Identify barriers to implementation of patient education, including literacy levels and language fluency.

• Determine the utility and appropriateness of patient education materials based on specific patient characteristics, which may include culture, literacy, cognitive ability, age, native language, and visual or other sensory impairments.

SKILLS

Hospitalists should be able to:

• Identify and assist patients and families who require additional education about their medical illnesses.

• Communicate effectively with patients from diverse backgrounds.

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

• Describe different methods of delivering patient education and effectively apply this knowledge to the care of individual patients.

• Utilize and/or develop methods and materials to fully inform patients and families.

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

• Provide patients with safety tips at the time of transfer of care, which may include instructions about medications, tests, procedures, alert symptoms to initiate a physician call, and follow‐up.

ATTITUDES

Hospitalists should be able to:

• Recognize the potential for patient education to improve the quality of health care.

• Encourage patients to ask questions, keep accurate medication lists and obtain test results.

• Ensure that patients understand anticipated therapies, procedures and/or surgery.

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

• Provide or arrange for patient education materials and programs for patients with chronic diseases.

• Advocate incorporation of patient wishes into care plans.

• Appreciate patient education as a tool to improve the experience of clinical care for both patients and families.

• Lead, coordinate or participate in the development of team‐based approaches to patient education.

• Lead, coordinate or participate in the development of effective quality measures sensitive to the effects of patient education.

The Institute of Medicine has defined patient centered care as one of the six aims for healthcare improvements in the 21^st century. Patient centered care requires that physicians and members of multidisciplinary teams effectively inform, educate, reassure and empower patients and families to participate in the creation and implementation of a care plan. Patient safety initiatives focus on the role of patient education in improving the quality of care from the perspective of both patients and clinicians. Hospitalists can develop and promote strategies to improve patient education initiatives and foster greater patient and family involvement in health care decisions and management.

KNOWLEDGE

Hospitalists should be able to:

• Describe the guiding principles for patient education.

• Explain the factors that impact the success or failure of behavior change strategies.

• Identify institutional resources for patient education materials and programs.

• Summarize the evidence for the primacy of patient education as a means to improve the quality of health care.

• Discuss the contextual factors that influence a patient's readiness to learn new information.

• Describe the role of patient education in the management of chronic diseases, which may include diabetes, congestive heart failure, and asthma.

• Explain how each patient's socio‐cultural background affects his or her health beliefs and behavior.

• Identify barriers to implementation of patient education, including literacy levels and language fluency.

• Determine the utility and appropriateness of patient education materials based on specific patient characteristics, which may include culture, literacy, cognitive ability, age, native language, and visual or other sensory impairments.

SKILLS

Hospitalists should be able to:

• Identify and assist patients and families who require additional education about their medical illnesses.

• Communicate effectively with patients from diverse backgrounds.

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

• Describe different methods of delivering patient education and effectively apply this knowledge to the care of individual patients.

• Utilize and/or develop methods and materials to fully inform patients and families.

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

• Provide patients with safety tips at the time of transfer of care, which may include instructions about medications, tests, procedures, alert symptoms to initiate a physician call, and follow‐up.

ATTITUDES

Hospitalists should be able to:

• Recognize the potential for patient education to improve the quality of health care.

• Encourage patients to ask questions, keep accurate medication lists and obtain test results.

• Ensure that patients understand anticipated therapies, procedures and/or surgery.

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

• Provide or arrange for patient education materials and programs for patients with chronic diseases.

• Advocate incorporation of patient wishes into care plans.

• Appreciate patient education as a tool to improve the experience of clinical care for both patients and families.

• Lead, coordinate or participate in the development of team‐based approaches to patient education.

• Lead, coordinate or participate in the development of effective quality measures sensitive to the effects of patient education.

The Institute of Medicine has defined patient centered care as one of the six aims for healthcare improvements in the 21^st century. Patient centered care requires that physicians and members of multidisciplinary teams effectively inform, educate, reassure and empower patients and families to participate in the creation and implementation of a care plan. Patient safety initiatives focus on the role of patient education in improving the quality of care from the perspective of both patients and clinicians. Hospitalists can develop and promote strategies to improve patient education initiatives and foster greater patient and family involvement in health care decisions and management.

KNOWLEDGE

Hospitalists should be able to:

• Describe the guiding principles for patient education.

• Explain the factors that impact the success or failure of behavior change strategies.

• Identify institutional resources for patient education materials and programs.

• Summarize the evidence for the primacy of patient education as a means to improve the quality of health care.

• Discuss the contextual factors that influence a patient's readiness to learn new information.

• Describe the role of patient education in the management of chronic diseases, which may include diabetes, congestive heart failure, and asthma.

• Explain how each patient's socio‐cultural background affects his or her health beliefs and behavior.

• Identify barriers to implementation of patient education, including literacy levels and language fluency.

• Determine the utility and appropriateness of patient education materials based on specific patient characteristics, which may include culture, literacy, cognitive ability, age, native language, and visual or other sensory impairments.

SKILLS

Hospitalists should be able to:

• Identify and assist patients and families who require additional education about their medical illnesses.

• Communicate effectively with patients from diverse backgrounds.

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

• Describe different methods of delivering patient education and effectively apply this knowledge to the care of individual patients.

• Utilize and/or develop methods and materials to fully inform patients and families.

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

• Provide patients with safety tips at the time of transfer of care, which may include instructions about medications, tests, procedures, alert symptoms to initiate a physician call, and follow‐up.

ATTITUDES

Hospitalists should be able to:

• Recognize the potential for patient education to improve the quality of health care.

• Encourage patients to ask questions, keep accurate medication lists and obtain test results.

• Ensure that patients understand anticipated therapies, procedures and/or surgery.

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

• Provide or arrange for patient education materials and programs for patients with chronic diseases.

• Advocate incorporation of patient wishes into care plans.

• Appreciate patient education as a tool to improve the experience of clinical care for both patients and families.

• Lead, coordinate or participate in the development of team‐based approaches to patient education.

• Lead, coordinate or participate in the development of effective quality measures sensitive to the effects of patient education.

Gastrointestinal (GI) bleed refers to any bleeding that originates in the GI tract. Bleeding is generally defined as upper (between the mouth and ligament of Treitz) or lower (from the ligament of Treitz to the anus). Healthcare Cost and Utilization Project (HCUP) 2002 data for the Diagnosis Related Group (DRG) for GI bleed with complications or co‐morbidities reveals approximately 409,000 discharges with an in‐hospital mortality of 3.0%. The mean length‐of‐stay for these patients was 4.4 days, with mean charges of $15,000. Hospitalists provide immediate care for these patients, who often require coordination of care across multiple specialties. Hospitalists lead quality improvement initiatives that optimize the efficiency and quality of care for these patients.

KNOWLEDGE

Hospitalists should be able to:

• Explain the multiple potential etiologies or pathophysiologic processes that lead to GI bleeds.

• Describe and differentiate the clinical features and presentations of upper and lower GI bleeds.

• Explain the differential diagnosis for the most common causes of upper and lower GI bleeds.

• Describe the indicated tests required to evaluate GI bleeds.

• Explain the risk factors for upper and lower GI bleeds, and clinical indicators of patients at high risk for complications.

• Explain the factors that may require early aggressive interventions or increase patient risk for recurrent bleeds.

• Risk stratify patients with GI bleeds and determine the level of care required.

• Describe the indications for transfusion therapy in GI bleeds, and explain the various methods of treatment for coagulopathy.

• Compare the advantages and disadvantages of medical, endoscopic, and surgical treatments for patients with upper and lower GI bleeds.

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

• Explain patient characteristics that on admission portend poor prognosis.

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

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

SKILLS

Hospitalists should be able to:

• Elicit a thorough and relevant history, including a directed medication, family and social history.

• Perform a physical examination and identify clinical indicators of upper and lower GI bleeds, and evidence of underlying states, which may include liver disease.

• Recognize physical findings that indicate clinical instability due to acute blood loss, including digital rectal examination, and interpretation of orthostatic blood pressure and pulse measurements.

• Insert a nasogastric tube, perform a gastric lavage, and interpret the results.

• Order and interpret results of appropriate laboratory, imaging, and endoscopic testing.

• Synthesize results of physical examination, laboratory and imaging studies to determine the best management and care plan for the patient.

• Formulate an evidence based treatment plan including nutritional recommendations, pharmacologic agents and dosing, and coordination of endoscopic and surgical interventions tailored to the individual patient.

• Determine frequency for laboratory monitoring and transfusion during hospitalization.

• Assure adequate intravenous access to allow rapid volume and blood product resuscitation.

• Perform rapid hemodynamic resuscitation.

• Recognize and treat signs of clinical decompensation and recurrent bleeding.

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

ATTITUDES

Hospitalists should be able to:

• Communicate with patients and families to explain the disease etiology, prognosis, risk reduction strategies, and symptoms of recurrent GI bleed.

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

• Communicate with patients and families to explain risks, benefits, and alternatives to transfusion therapy.

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

• Recognize the indications for early specialty consultation, which may include interventional radiology, gastroenterology and surgery.

• Initiate prevention measures including avoidance of NSAIDs, stress ulcer prophylaxis in critically ill patients, dietary modification, and evidence based medical therapies.

• Employ a multidisciplinary approach, which may include nursing, pharmacy and nutrition services, and specialty and referring physicians, to the care of patients with GI bleeds.

• Employ a multidisciplinary approach to the care of patients with GI bleed that begins at admission and continues through all care transitions.

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

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

• Inform receiving physician of pending study results.

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

SYSTEM ORGANIZATION AND IMPROVEMENT

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

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

• Lead, coordinate or participate in multidisciplinary teams, which may include emergency medicine physicians, gastroenterologists and nurses, to develop quality improvement initiatives that promote early identification of GI bleeds and reduce preventable complications.

• Develop systems that provide timely reports of pending study results to outpatient providers.

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

Gastrointestinal (GI) bleed refers to any bleeding that originates in the GI tract. Bleeding is generally defined as upper (between the mouth and ligament of Treitz) or lower (from the ligament of Treitz to the anus). Healthcare Cost and Utilization Project (HCUP) 2002 data for the Diagnosis Related Group (DRG) for GI bleed with complications or co‐morbidities reveals approximately 409,000 discharges with an in‐hospital mortality of 3.0%. The mean length‐of‐stay for these patients was 4.4 days, with mean charges of $15,000. Hospitalists provide immediate care for these patients, who often require coordination of care across multiple specialties. Hospitalists lead quality improvement initiatives that optimize the efficiency and quality of care for these patients.

KNOWLEDGE

Hospitalists should be able to:

• Explain the multiple potential etiologies or pathophysiologic processes that lead to GI bleeds.

• Describe and differentiate the clinical features and presentations of upper and lower GI bleeds.

• Explain the differential diagnosis for the most common causes of upper and lower GI bleeds.

• Describe the indicated tests required to evaluate GI bleeds.

• Explain the risk factors for upper and lower GI bleeds, and clinical indicators of patients at high risk for complications.

• Explain the factors that may require early aggressive interventions or increase patient risk for recurrent bleeds.

• Risk stratify patients with GI bleeds and determine the level of care required.

• Describe the indications for transfusion therapy in GI bleeds, and explain the various methods of treatment for coagulopathy.

• Compare the advantages and disadvantages of medical, endoscopic, and surgical treatments for patients with upper and lower GI bleeds.

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

• Explain patient characteristics that on admission portend poor prognosis.

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

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

SKILLS

Hospitalists should be able to:

• Elicit a thorough and relevant history, including a directed medication, family and social history.

• Perform a physical examination and identify clinical indicators of upper and lower GI bleeds, and evidence of underlying states, which may include liver disease.

• Recognize physical findings that indicate clinical instability due to acute blood loss, including digital rectal examination, and interpretation of orthostatic blood pressure and pulse measurements.

• Insert a nasogastric tube, perform a gastric lavage, and interpret the results.

• Order and interpret results of appropriate laboratory, imaging, and endoscopic testing.

• Synthesize results of physical examination, laboratory and imaging studies to determine the best management and care plan for the patient.

• Formulate an evidence based treatment plan including nutritional recommendations, pharmacologic agents and dosing, and coordination of endoscopic and surgical interventions tailored to the individual patient.

• Determine frequency for laboratory monitoring and transfusion during hospitalization.

• Assure adequate intravenous access to allow rapid volume and blood product resuscitation.

• Perform rapid hemodynamic resuscitation.

• Recognize and treat signs of clinical decompensation and recurrent bleeding.

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

ATTITUDES

Hospitalists should be able to:

• Communicate with patients and families to explain the disease etiology, prognosis, risk reduction strategies, and symptoms of recurrent GI bleed.

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

• Communicate with patients and families to explain risks, benefits, and alternatives to transfusion therapy.

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

• Recognize the indications for early specialty consultation, which may include interventional radiology, gastroenterology and surgery.

• Initiate prevention measures including avoidance of NSAIDs, stress ulcer prophylaxis in critically ill patients, dietary modification, and evidence based medical therapies.

• Employ a multidisciplinary approach, which may include nursing, pharmacy and nutrition services, and specialty and referring physicians, to the care of patients with GI bleeds.

• Employ a multidisciplinary approach to the care of patients with GI bleed that begins at admission and continues through all care transitions.

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

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

• Inform receiving physician of pending study results.

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

SYSTEM ORGANIZATION AND IMPROVEMENT

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

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

• Lead, coordinate or participate in multidisciplinary teams, which may include emergency medicine physicians, gastroenterologists and nurses, to develop quality improvement initiatives that promote early identification of GI bleeds and reduce preventable complications.

• Develop systems that provide timely reports of pending study results to outpatient providers.

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

Gastrointestinal (GI) bleed refers to any bleeding that originates in the GI tract. Bleeding is generally defined as upper (between the mouth and ligament of Treitz) or lower (from the ligament of Treitz to the anus). Healthcare Cost and Utilization Project (HCUP) 2002 data for the Diagnosis Related Group (DRG) for GI bleed with complications or co‐morbidities reveals approximately 409,000 discharges with an in‐hospital mortality of 3.0%. The mean length‐of‐stay for these patients was 4.4 days, with mean charges of $15,000. Hospitalists provide immediate care for these patients, who often require coordination of care across multiple specialties. Hospitalists lead quality improvement initiatives that optimize the efficiency and quality of care for these patients.

KNOWLEDGE

Hospitalists should be able to:

• Explain the multiple potential etiologies or pathophysiologic processes that lead to GI bleeds.

• Describe and differentiate the clinical features and presentations of upper and lower GI bleeds.

• Explain the differential diagnosis for the most common causes of upper and lower GI bleeds.

• Describe the indicated tests required to evaluate GI bleeds.

• Explain the risk factors for upper and lower GI bleeds, and clinical indicators of patients at high risk for complications.

• Explain the factors that may require early aggressive interventions or increase patient risk for recurrent bleeds.

• Risk stratify patients with GI bleeds and determine the level of care required.

• Describe the indications for transfusion therapy in GI bleeds, and explain the various methods of treatment for coagulopathy.

• Compare the advantages and disadvantages of medical, endoscopic, and surgical treatments for patients with upper and lower GI bleeds.

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

• Explain patient characteristics that on admission portend poor prognosis.

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

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

SKILLS

Hospitalists should be able to:

• Elicit a thorough and relevant history, including a directed medication, family and social history.

• Perform a physical examination and identify clinical indicators of upper and lower GI bleeds, and evidence of underlying states, which may include liver disease.

• Recognize physical findings that indicate clinical instability due to acute blood loss, including digital rectal examination, and interpretation of orthostatic blood pressure and pulse measurements.

• Insert a nasogastric tube, perform a gastric lavage, and interpret the results.

• Order and interpret results of appropriate laboratory, imaging, and endoscopic testing.

• Synthesize results of physical examination, laboratory and imaging studies to determine the best management and care plan for the patient.

• Formulate an evidence based treatment plan including nutritional recommendations, pharmacologic agents and dosing, and coordination of endoscopic and surgical interventions tailored to the individual patient.

• Determine frequency for laboratory monitoring and transfusion during hospitalization.

• Assure adequate intravenous access to allow rapid volume and blood product resuscitation.

• Perform rapid hemodynamic resuscitation.

• Recognize and treat signs of clinical decompensation and recurrent bleeding.

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

ATTITUDES

Hospitalists should be able to:

• Communicate with patients and families to explain the disease etiology, prognosis, risk reduction strategies, and symptoms of recurrent GI bleed.

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

• Communicate with patients and families to explain risks, benefits, and alternatives to transfusion therapy.

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

• Recognize the indications for early specialty consultation, which may include interventional radiology, gastroenterology and surgery.

• Initiate prevention measures including avoidance of NSAIDs, stress ulcer prophylaxis in critically ill patients, dietary modification, and evidence based medical therapies.

• Employ a multidisciplinary approach, which may include nursing, pharmacy and nutrition services, and specialty and referring physicians, to the care of patients with GI bleeds.

• Employ a multidisciplinary approach to the care of patients with GI bleed that begins at admission and continues through all care transitions.

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

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

• Inform receiving physician of pending study results.

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

SYSTEM ORGANIZATION AND IMPROVEMENT

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

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

• Lead, coordinate or participate in multidisciplinary teams, which may include emergency medicine physicians, gastroenterologists and nurses, to develop quality improvement initiatives that promote early identification of GI bleeds and reduce preventable complications.

• Develop systems that provide timely reports of pending study results to outpatient providers.

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

Optimal nutrition in the hospital can facilitate better patient outcomes. Malnutrition in hospitalized patients can lead to poor wound healing, impaired immune function resulting in infectious complications, increased hospital length of stay, and overall increased morbidity and mortality. The prevalence of malnutrition has been reported in up to 50% of hospitalized patients. Early screening for nutritional risk allows for appropriate intervention in the hospital setting, as well as planning for appropriate home services and follow‐up for outpatient nutritional care. Hospitalists use a multidisciplinary approach to evaluate and address the nutritional needs of hospitalized patients. Hospitalists lead, coordinate or participate in multidisciplinary initiatives to improve the nutritional status of hospitalized patients.

KNOWLEDGE

Hospitalists should be able to:

• Describe methods of screening for malnutrition.

• Identify when a nutrition evaluation by a registered dietitian is required.

• Differentiate between basic modified diets and explain the indications for each (sodium, diabetic, renal, and different dietary consistencies).

• Explain the indications and contraindications for enteral nutrition.

• Describe the indications for parenteral nutrition.

• Describe potential complications associated with enteral and parenteral nutrition.

• Explain risk factors for the re‐feeding syndrome.

SKILLS

Hospitalists should be able to:

• Use objective criteria to determine if a patient is malnourished.

• Determine appropriate laboratory measures to ascertain presence of malnutrition.

• Utilize individualized modified diets and/or nutritional supplements, which may include total parenteral nutrition, based on the patient's medical condition.

• Choose an appropriate enteral nutrition formula when indicated.

• Treat for electrolyte abnormalities associated with the re‐feeding syndrome.

• Monitor electrolytes as indicated in the setting of enteral and/or parenteral nutritional support.

ATTITUDES

Hospitalists should be able to:

• Recognize the importance of adequate nutrition in hospitalized patients.

• Recognize when a nutrition evaluation by a registered dietitian is required.

• Consult a nutrition specialist for a comprehensive nutritional evaluation when indicated.

• Collaborate with clinical nutrition staff to implement the nutrition care plan.

• Utilize a team approach for early discharge planning for patients requiring home parenteral or enteral nutrition.

• Recognize that specialized nutritional supplementation may be required in certain patient populations, which may include patients with extensive wounds or increased catabolic needs.

• Implement routine nutrition screening to identify malnourished patients early in admission.

• Lead, coordinate or participate in the development of care pathways for patients requiring enteral or parenteral nutrition.

• Coordinate follow‐up nutrition care as part of discharge plans for those patients requiring nutritional support.

Optimal nutrition in the hospital can facilitate better patient outcomes. Malnutrition in hospitalized patients can lead to poor wound healing, impaired immune function resulting in infectious complications, increased hospital length of stay, and overall increased morbidity and mortality. The prevalence of malnutrition has been reported in up to 50% of hospitalized patients. Early screening for nutritional risk allows for appropriate intervention in the hospital setting, as well as planning for appropriate home services and follow‐up for outpatient nutritional care. Hospitalists use a multidisciplinary approach to evaluate and address the nutritional needs of hospitalized patients. Hospitalists lead, coordinate or participate in multidisciplinary initiatives to improve the nutritional status of hospitalized patients.

KNOWLEDGE

Hospitalists should be able to:

• Describe methods of screening for malnutrition.

• Identify when a nutrition evaluation by a registered dietitian is required.

• Differentiate between basic modified diets and explain the indications for each (sodium, diabetic, renal, and different dietary consistencies).

• Explain the indications and contraindications for enteral nutrition.

• Describe the indications for parenteral nutrition.

• Describe potential complications associated with enteral and parenteral nutrition.

• Explain risk factors for the re‐feeding syndrome.

SKILLS

Hospitalists should be able to:

• Use objective criteria to determine if a patient is malnourished.

• Determine appropriate laboratory measures to ascertain presence of malnutrition.

• Utilize individualized modified diets and/or nutritional supplements, which may include total parenteral nutrition, based on the patient's medical condition.

• Choose an appropriate enteral nutrition formula when indicated.

• Treat for electrolyte abnormalities associated with the re‐feeding syndrome.

• Monitor electrolytes as indicated in the setting of enteral and/or parenteral nutritional support.

ATTITUDES

Hospitalists should be able to:

• Recognize the importance of adequate nutrition in hospitalized patients.

• Recognize when a nutrition evaluation by a registered dietitian is required.

• Consult a nutrition specialist for a comprehensive nutritional evaluation when indicated.

• Collaborate with clinical nutrition staff to implement the nutrition care plan.

• Utilize a team approach for early discharge planning for patients requiring home parenteral or enteral nutrition.

• Recognize that specialized nutritional supplementation may be required in certain patient populations, which may include patients with extensive wounds or increased catabolic needs.

• Implement routine nutrition screening to identify malnourished patients early in admission.

• Lead, coordinate or participate in the development of care pathways for patients requiring enteral or parenteral nutrition.

• Coordinate follow‐up nutrition care as part of discharge plans for those patients requiring nutritional support.

Optimal nutrition in the hospital can facilitate better patient outcomes. Malnutrition in hospitalized patients can lead to poor wound healing, impaired immune function resulting in infectious complications, increased hospital length of stay, and overall increased morbidity and mortality. The prevalence of malnutrition has been reported in up to 50% of hospitalized patients. Early screening for nutritional risk allows for appropriate intervention in the hospital setting, as well as planning for appropriate home services and follow‐up for outpatient nutritional care. Hospitalists use a multidisciplinary approach to evaluate and address the nutritional needs of hospitalized patients. Hospitalists lead, coordinate or participate in multidisciplinary initiatives to improve the nutritional status of hospitalized patients.

KNOWLEDGE

Hospitalists should be able to:

• Describe methods of screening for malnutrition.

• Identify when a nutrition evaluation by a registered dietitian is required.

• Differentiate between basic modified diets and explain the indications for each (sodium, diabetic, renal, and different dietary consistencies).

• Explain the indications and contraindications for enteral nutrition.

• Describe the indications for parenteral nutrition.

• Describe potential complications associated with enteral and parenteral nutrition.

• Explain risk factors for the re‐feeding syndrome.

SKILLS

Hospitalists should be able to:

• Use objective criteria to determine if a patient is malnourished.

• Determine appropriate laboratory measures to ascertain presence of malnutrition.

• Utilize individualized modified diets and/or nutritional supplements, which may include total parenteral nutrition, based on the patient's medical condition.

• Choose an appropriate enteral nutrition formula when indicated.

• Treat for electrolyte abnormalities associated with the re‐feeding syndrome.

• Monitor electrolytes as indicated in the setting of enteral and/or parenteral nutritional support.

ATTITUDES

Hospitalists should be able to:

• Recognize the importance of adequate nutrition in hospitalized patients.

• Recognize when a nutrition evaluation by a registered dietitian is required.

• Consult a nutrition specialist for a comprehensive nutritional evaluation when indicated.

• Collaborate with clinical nutrition staff to implement the nutrition care plan.

• Utilize a team approach for early discharge planning for patients requiring home parenteral or enteral nutrition.

• Recognize that specialized nutritional supplementation may be required in certain patient populations, which may include patients with extensive wounds or increased catabolic needs.

• Implement routine nutrition screening to identify malnourished patients early in admission.

• Lead, coordinate or participate in the development of care pathways for patients requiring enteral or parenteral nutrition.

• Coordinate follow‐up nutrition care as part of discharge plans for those patients requiring nutritional support.

Evidence based medicine (EBM) uses a systematic approach to medical decision making and patient care, combining the highest‐available level of scientific evidence with practitioner clinical judgment and patient values and preferences. For hospitalists facing multiple critical medical choices daily, an EBM approach helps clinicians collaborate with patients to make the best possible decisions for their inpatient care. Hospitalists use study evidence to answer clinical questions and to develop quality improvement projects, including protocols and clinical pathways that can improve the efficiency, quality, and safety of care within their organizations. Hospitalists further provide leadership in educational efforts that foster a rigorous evidence based approach among medical trainees, hospital staff, and physician colleagues.

KNOWLEDGE

Hospitalists should be able to:

• Describe the necessary steps required to ask and answer clinical questions using standardized EBM methods.

• Describe the four core components of framing clinical questions using an EBM approach.

• Identify peer‐reviewed databases and other resources to search for study evidence to answer clinical and systems questions.

• Differentiate between filtered and non‐filtered resources, list examples of each, and describe the advantages and disadvantages of each.

• Describe major study types including therapy, diagnosis, prognosis, harm, meta‐analysis (systematic review), economic analysis, and decision analysis.

• Describe and differentiate the important strengths and weaknesses of the following study designs: randomized controlled trials, meta‐analyses, cohort studies, case‐control studies, case series, cost‐effectiveness studies, and clinical decision analysis studies.

• Explain the core components and core statistical concepts used in therapy studies, including relative risk, Relative Risk Reduction (RRR), Absolute Risk Reduction (ARR), Number Needed to Treat (NNT) and diagnosis studies, which may include sensitivity, specificity, and likelihood ratio.

SKILLS

Hospitalists should be able to:

• Formulate a well‐designed clinical question using the Patient Intervention Comparison Outcome (PICO) approach.

• Identify the most appropriate study design(s) for the specific clinical or systems based question at hand.

• Search filtered and non‐filtered information resources efficiently to find answers to clinical questions.

• Critically appraise the validity of individual study methodology and reporting.

• Evaluate and interpret study results, including useful point estimates and precision analysis.

• Apply relevant results of validated studies to individual patient care or systems improvement projects.

ATTITUDES

Hospitalists should be able to:

• Seek the best available evidence to support clinical decisions and process improvements at the individual and institutional level.

• Appreciate that filtered resources allow greater efficiency than non‐filtered resources in searching for answers to clinical and systems questions and locating high‐quality evidence.

• Reflect upon individual practice patterns to identify new questions.

• Develop a process for the ongoing incorporation of new information into existing clinical practice and system improvement projects.

• Serve as a role model for evidence based point‐of‐care practice.

• Influence and support other clinicians to develop and utilize EBM skills to improve clinical practice and systems or processes within practice.

• Lead, coordinate or participate in systems interventions to improve the quality, efficiency and standardization of care based on EBM review of the literature.

• Advocate for the institution to provide or facilitate access to high quality point‐of‐care EBM information resources.

Evidence based medicine (EBM) uses a systematic approach to medical decision making and patient care, combining the highest‐available level of scientific evidence with practitioner clinical judgment and patient values and preferences. For hospitalists facing multiple critical medical choices daily, an EBM approach helps clinicians collaborate with patients to make the best possible decisions for their inpatient care. Hospitalists use study evidence to answer clinical questions and to develop quality improvement projects, including protocols and clinical pathways that can improve the efficiency, quality, and safety of care within their organizations. Hospitalists further provide leadership in educational efforts that foster a rigorous evidence based approach among medical trainees, hospital staff, and physician colleagues.

KNOWLEDGE

Hospitalists should be able to:

• Describe the necessary steps required to ask and answer clinical questions using standardized EBM methods.

• Describe the four core components of framing clinical questions using an EBM approach.

• Identify peer‐reviewed databases and other resources to search for study evidence to answer clinical and systems questions.

• Differentiate between filtered and non‐filtered resources, list examples of each, and describe the advantages and disadvantages of each.

• Describe major study types including therapy, diagnosis, prognosis, harm, meta‐analysis (systematic review), economic analysis, and decision analysis.

• Describe and differentiate the important strengths and weaknesses of the following study designs: randomized controlled trials, meta‐analyses, cohort studies, case‐control studies, case series, cost‐effectiveness studies, and clinical decision analysis studies.

• Explain the core components and core statistical concepts used in therapy studies, including relative risk, Relative Risk Reduction (RRR), Absolute Risk Reduction (ARR), Number Needed to Treat (NNT) and diagnosis studies, which may include sensitivity, specificity, and likelihood ratio.

SKILLS

Hospitalists should be able to:

• Formulate a well‐designed clinical question using the Patient Intervention Comparison Outcome (PICO) approach.

• Identify the most appropriate study design(s) for the specific clinical or systems based question at hand.

• Search filtered and non‐filtered information resources efficiently to find answers to clinical questions.

• Critically appraise the validity of individual study methodology and reporting.

• Evaluate and interpret study results, including useful point estimates and precision analysis.

• Apply relevant results of validated studies to individual patient care or systems improvement projects.

ATTITUDES

Hospitalists should be able to:

• Seek the best available evidence to support clinical decisions and process improvements at the individual and institutional level.

• Appreciate that filtered resources allow greater efficiency than non‐filtered resources in searching for answers to clinical and systems questions and locating high‐quality evidence.

• Reflect upon individual practice patterns to identify new questions.

• Develop a process for the ongoing incorporation of new information into existing clinical practice and system improvement projects.

• Serve as a role model for evidence based point‐of‐care practice.

• Influence and support other clinicians to develop and utilize EBM skills to improve clinical practice and systems or processes within practice.

• Lead, coordinate or participate in systems interventions to improve the quality, efficiency and standardization of care based on EBM review of the literature.

• Advocate for the institution to provide or facilitate access to high quality point‐of‐care EBM information resources.

Evidence based medicine (EBM) uses a systematic approach to medical decision making and patient care, combining the highest‐available level of scientific evidence with practitioner clinical judgment and patient values and preferences. For hospitalists facing multiple critical medical choices daily, an EBM approach helps clinicians collaborate with patients to make the best possible decisions for their inpatient care. Hospitalists use study evidence to answer clinical questions and to develop quality improvement projects, including protocols and clinical pathways that can improve the efficiency, quality, and safety of care within their organizations. Hospitalists further provide leadership in educational efforts that foster a rigorous evidence based approach among medical trainees, hospital staff, and physician colleagues.

KNOWLEDGE

Hospitalists should be able to:

• Describe the necessary steps required to ask and answer clinical questions using standardized EBM methods.

• Describe the four core components of framing clinical questions using an EBM approach.

• Identify peer‐reviewed databases and other resources to search for study evidence to answer clinical and systems questions.

• Differentiate between filtered and non‐filtered resources, list examples of each, and describe the advantages and disadvantages of each.

• Describe major study types including therapy, diagnosis, prognosis, harm, meta‐analysis (systematic review), economic analysis, and decision analysis.

• Describe and differentiate the important strengths and weaknesses of the following study designs: randomized controlled trials, meta‐analyses, cohort studies, case‐control studies, case series, cost‐effectiveness studies, and clinical decision analysis studies.

• Explain the core components and core statistical concepts used in therapy studies, including relative risk, Relative Risk Reduction (RRR), Absolute Risk Reduction (ARR), Number Needed to Treat (NNT) and diagnosis studies, which may include sensitivity, specificity, and likelihood ratio.

SKILLS

Hospitalists should be able to:

• Formulate a well‐designed clinical question using the Patient Intervention Comparison Outcome (PICO) approach.

• Identify the most appropriate study design(s) for the specific clinical or systems based question at hand.

• Search filtered and non‐filtered information resources efficiently to find answers to clinical questions.

• Critically appraise the validity of individual study methodology and reporting.

• Evaluate and interpret study results, including useful point estimates and precision analysis.

• Apply relevant results of validated studies to individual patient care or systems improvement projects.

ATTITUDES

Hospitalists should be able to:

• Seek the best available evidence to support clinical decisions and process improvements at the individual and institutional level.

• Appreciate that filtered resources allow greater efficiency than non‐filtered resources in searching for answers to clinical and systems questions and locating high‐quality evidence.

• Reflect upon individual practice patterns to identify new questions.

• Develop a process for the ongoing incorporation of new information into existing clinical practice and system improvement projects.

• Serve as a role model for evidence based point‐of‐care practice.

• Influence and support other clinicians to develop and utilize EBM skills to improve clinical practice and systems or processes within practice.

• Lead, coordinate or participate in systems interventions to improve the quality, efficiency and standardization of care based on EBM review of the literature.

• Advocate for the institution to provide or facilitate access to high quality point‐of‐care EBM information resources.

ABIM American Board of Internal Medicine (www.abim.org)

ABP American Board of Pediatrics (www.abp.org)

ACC American College of Cardiology (www.acc.org)

ACGME Accreditation Council for Graduate Medical Education (www.acgme.org)

ACLS Advanced Cardiac Life Support (www.americanheart.org or www.acls.net)

ADA American Diabetes Association (www.diabetes.org)

AHA American Heart Association (www.americanheart.org)

AHRQ Agency for Healthcare Research and Quality (www.ahrq.gov)

ATS American Thoracic Society (www.thoracic.org)

BLS Basic Life Support (www.americanheart.org or www.basiclifesupport.net)

CDCP Centers for Disease Control and Prevention (www.cdc.gov)

EMTALA Emergency Medical Treatment and Active Labor Act (www.emtala.com)

FDA Food and Drug Administration (www.fda.gov)

HCUP Healthcare Cost and Utilization Project (www.ahrq.gov/data/hcup)

HIPAA Health Insurance Portability and Accountability Act (http://aspe.hhs.gov)

IASP International Association for the Study of Pain (www.iasp‐pain.org)

IDSA Infectious Diseases Society of America (www.idsociety.org)

IOM Institute of Medicine (www.iom.edu)

JCAHO Joint Commission on Accreditation of Healthcare Organizations (www.jcaho.org)

NPSF National Patient Safety Foundation (www.npsf.org)

NIS Nationwide Inpatient Sample (www.hcup‐us.ahrq.gov/nisoverview.jsp)

SHM Society of Hospital Medicine (www.hospitalmedicine.org)

WHO World Health Organization (www.who.int/en/)

ABIM American Board of Internal Medicine (www.abim.org)

ABP American Board of Pediatrics (www.abp.org)

ACC American College of Cardiology (www.acc.org)

ACGME Accreditation Council for Graduate Medical Education (www.acgme.org)

ACLS Advanced Cardiac Life Support (www.americanheart.org or www.acls.net)

ADA American Diabetes Association (www.diabetes.org)

AHA American Heart Association (www.americanheart.org)

AHRQ Agency for Healthcare Research and Quality (www.ahrq.gov)

ATS American Thoracic Society (www.thoracic.org)

BLS Basic Life Support (www.americanheart.org or www.basiclifesupport.net)

CDCP Centers for Disease Control and Prevention (www.cdc.gov)

EMTALA Emergency Medical Treatment and Active Labor Act (www.emtala.com)

FDA Food and Drug Administration (www.fda.gov)

HCUP Healthcare Cost and Utilization Project (www.ahrq.gov/data/hcup)

HIPAA Health Insurance Portability and Accountability Act (http://aspe.hhs.gov)

IASP International Association for the Study of Pain (www.iasp‐pain.org)

IDSA Infectious Diseases Society of America (www.idsociety.org)

IOM Institute of Medicine (www.iom.edu)

JCAHO Joint Commission on Accreditation of Healthcare Organizations (www.jcaho.org)

NPSF National Patient Safety Foundation (www.npsf.org)

NIS Nationwide Inpatient Sample (www.hcup‐us.ahrq.gov/nisoverview.jsp)

SHM Society of Hospital Medicine (www.hospitalmedicine.org)

WHO World Health Organization (www.who.int/en/)

ABIM American Board of Internal Medicine (www.abim.org)

ABP American Board of Pediatrics (www.abp.org)

ACC American College of Cardiology (www.acc.org)

ACGME Accreditation Council for Graduate Medical Education (www.acgme.org)

ACLS Advanced Cardiac Life Support (www.americanheart.org or www.acls.net)

ADA American Diabetes Association (www.diabetes.org)

AHA American Heart Association (www.americanheart.org)

AHRQ Agency for Healthcare Research and Quality (www.ahrq.gov)

ATS American Thoracic Society (www.thoracic.org)

BLS Basic Life Support (www.americanheart.org or www.basiclifesupport.net)

CDCP Centers for Disease Control and Prevention (www.cdc.gov)

EMTALA Emergency Medical Treatment and Active Labor Act (www.emtala.com)

FDA Food and Drug Administration (www.fda.gov)

HCUP Healthcare Cost and Utilization Project (www.ahrq.gov/data/hcup)

HIPAA Health Insurance Portability and Accountability Act (http://aspe.hhs.gov)

IASP International Association for the Study of Pain (www.iasp‐pain.org)

IDSA Infectious Diseases Society of America (www.idsociety.org)

IOM Institute of Medicine (www.iom.edu)

JCAHO Joint Commission on Accreditation of Healthcare Organizations (www.jcaho.org)

NPSF National Patient Safety Foundation (www.npsf.org)

NIS Nationwide Inpatient Sample (www.hcup‐us.ahrq.gov/nisoverview.jsp)

SHM Society of Hospital Medicine (www.hospitalmedicine.org)

WHO World Health Organization (www.who.int/en/)

Arthrocentesis, the aspiration of synovial fluid from a joint, is frequently performed in the diagnosis and management of joint effusions. These effusions are associated with infectious, traumatic, and rheumatologic conditions. The Healthcare Cost and Utilization Project (HCUP) reports that arthrocentesis was performed in 32,961 hospitalized patients in 2002. Hospitalists may identify a joint effusion during the history and physical examination, and should use clinical expertise and evidence based decision making to determine whether arthrocentesis is required in the diagnosis and management of the patient's illness.

KNOWLEDGE

Hospitalists should be able to:

• Identify and locate anatomic landmarks to guide proper entry points for arthrocentesis.

• Define and differentiate the disease processes that may lead to the development of joint effusion.

• Explain the indications and contraindications for arthrocentesis, including potential risks and complications.

• Explain the appropriate diagnostic testing for synovial fluid.

• Describe indications for use of ultrasonography to guide arthrocentesis.

• Select the necessary equipment to perform an arthrocentesis at the bedside.

SKILLS

Hospitalists should be able to:

• Distinguish between the clinical features of a joint effusion and soft tissue swelling surrounding a joint.

• Demonstrate the optimal position for the patient and the patient's joint during an arthrocentesis.

• Select and use the correct equipment for a given joint.

• Use sterile techniques during preparation for and performance of arthrocentesis.

• Maintain clinician safety with appropriate protective wear.

• Manage the complications of arthrocentesis.

• Order radiographic studies and interpret findings.

• Order and interpret results of synovial fluid cell count, differential, crystal morphology, gram stain and culture.

• Order and interpret platelet and coagulation studies when indicated.

• Develop management plan based on results of fluid testing.

ATTITUDES

Hospitalists should be able to:

• Communicate with patients and families to explain the procedure, its expected diagnostic or therapeutic benefits, recovery period, and potential and expected outcomes; and to obtain informed consent.

• Discuss with patients and families pain management strategies for discomfort during and after arthrocentesis.

• Relieve pain with splinting and analgesia targeted to the joint inflammation.

• Employ multidisciplinary teams, including physical and occupational therapy when appropriate, to assist with inpatient and outpatient rehabilitation.

• Recognize indications for specialty consultation, which may include rheumatology, orthopaedics or infectious disease.

• Consider early consultation in the management of effusion in a prosthetic joint.

SYSTEM ORGANIZATION AND IMPROVEMENT

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

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

• Lead, coordinate or participate in efforts to develop strategies to minimize institutional complication rates.

• Lead, coordinate or participate in quality improvement programs to monitor hospitalists' performance and/or supervision of arthrocentesis.

• Lead, coordinate or participate in efforts to organize and consolidate arthrocentesis equipment in an identifiable location in the hospital, easily assessable to clinicians who perform the procedure.

Arthrocentesis, the aspiration of synovial fluid from a joint, is frequently performed in the diagnosis and management of joint effusions. These effusions are associated with infectious, traumatic, and rheumatologic conditions. The Healthcare Cost and Utilization Project (HCUP) reports that arthrocentesis was performed in 32,961 hospitalized patients in 2002. Hospitalists may identify a joint effusion during the history and physical examination, and should use clinical expertise and evidence based decision making to determine whether arthrocentesis is required in the diagnosis and management of the patient's illness.

KNOWLEDGE

Hospitalists should be able to:

• Identify and locate anatomic landmarks to guide proper entry points for arthrocentesis.

• Define and differentiate the disease processes that may lead to the development of joint effusion.

• Explain the indications and contraindications for arthrocentesis, including potential risks and complications.

• Explain the appropriate diagnostic testing for synovial fluid.

• Describe indications for use of ultrasonography to guide arthrocentesis.

• Select the necessary equipment to perform an arthrocentesis at the bedside.

SKILLS

Hospitalists should be able to:

• Distinguish between the clinical features of a joint effusion and soft tissue swelling surrounding a joint.

• Demonstrate the optimal position for the patient and the patient's joint during an arthrocentesis.

• Select and use the correct equipment for a given joint.

• Use sterile techniques during preparation for and performance of arthrocentesis.

• Maintain clinician safety with appropriate protective wear.

• Manage the complications of arthrocentesis.

• Order radiographic studies and interpret findings.

• Order and interpret results of synovial fluid cell count, differential, crystal morphology, gram stain and culture.

• Order and interpret platelet and coagulation studies when indicated.

• Develop management plan based on results of fluid testing.

ATTITUDES

Hospitalists should be able to:

• Communicate with patients and families to explain the procedure, its expected diagnostic or therapeutic benefits, recovery period, and potential and expected outcomes; and to obtain informed consent.

• Discuss with patients and families pain management strategies for discomfort during and after arthrocentesis.

• Relieve pain with splinting and analgesia targeted to the joint inflammation.

• Employ multidisciplinary teams, including physical and occupational therapy when appropriate, to assist with inpatient and outpatient rehabilitation.

• Recognize indications for specialty consultation, which may include rheumatology, orthopaedics or infectious disease.

• Consider early consultation in the management of effusion in a prosthetic joint.

SYSTEM ORGANIZATION AND IMPROVEMENT

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

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

• Lead, coordinate or participate in efforts to develop strategies to minimize institutional complication rates.

• Lead, coordinate or participate in quality improvement programs to monitor hospitalists' performance and/or supervision of arthrocentesis.

• Lead, coordinate or participate in efforts to organize and consolidate arthrocentesis equipment in an identifiable location in the hospital, easily assessable to clinicians who perform the procedure.

Arthrocentesis, the aspiration of synovial fluid from a joint, is frequently performed in the diagnosis and management of joint effusions. These effusions are associated with infectious, traumatic, and rheumatologic conditions. The Healthcare Cost and Utilization Project (HCUP) reports that arthrocentesis was performed in 32,961 hospitalized patients in 2002. Hospitalists may identify a joint effusion during the history and physical examination, and should use clinical expertise and evidence based decision making to determine whether arthrocentesis is required in the diagnosis and management of the patient's illness.

KNOWLEDGE

Hospitalists should be able to:

• Identify and locate anatomic landmarks to guide proper entry points for arthrocentesis.

• Define and differentiate the disease processes that may lead to the development of joint effusion.

• Explain the indications and contraindications for arthrocentesis, including potential risks and complications.

• Explain the appropriate diagnostic testing for synovial fluid.

• Describe indications for use of ultrasonography to guide arthrocentesis.

• Select the necessary equipment to perform an arthrocentesis at the bedside.

SKILLS

Hospitalists should be able to:

• Distinguish between the clinical features of a joint effusion and soft tissue swelling surrounding a joint.

• Demonstrate the optimal position for the patient and the patient's joint during an arthrocentesis.

• Select and use the correct equipment for a given joint.

• Use sterile techniques during preparation for and performance of arthrocentesis.

• Maintain clinician safety with appropriate protective wear.

• Manage the complications of arthrocentesis.

• Order radiographic studies and interpret findings.

• Order and interpret results of synovial fluid cell count, differential, crystal morphology, gram stain and culture.

• Order and interpret platelet and coagulation studies when indicated.

• Develop management plan based on results of fluid testing.

ATTITUDES

Hospitalists should be able to:

• Communicate with patients and families to explain the procedure, its expected diagnostic or therapeutic benefits, recovery period, and potential and expected outcomes; and to obtain informed consent.

• Discuss with patients and families pain management strategies for discomfort during and after arthrocentesis.

• Relieve pain with splinting and analgesia targeted to the joint inflammation.

• Employ multidisciplinary teams, including physical and occupational therapy when appropriate, to assist with inpatient and outpatient rehabilitation.

• Recognize indications for specialty consultation, which may include rheumatology, orthopaedics or infectious disease.

• Consider early consultation in the management of effusion in a prosthetic joint.

SYSTEM ORGANIZATION AND IMPROVEMENT

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

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

• Lead, coordinate or participate in efforts to develop strategies to minimize institutional complication rates.

• Lead, coordinate or participate in quality improvement programs to monitor hospitalists' performance and/or supervision of arthrocentesis.

• Lead, coordinate or participate in efforts to organize and consolidate arthrocentesis equipment in an identifiable location in the hospital, easily assessable to clinicians who perform the procedure.

Heart disease continues to be the leading cause of hospital admissions and mortality in the United States, accounting for an estimated 13% of admissions in 2001, and 21% of in‐hospital deaths in 2000. The electrocardiogram (EKG), a graphical representation of cardiac electrical potentials, is a noninvasive, readily available diagnostic tool. It remains the most commonly used investigative modality for the initial evaluation of cardiovascular disease. Hospitalists interpret these results expediently and apply the results to estimate risk, diagnose disease, and determine therapeutic needs in the hospitalized patient.

KNOWLEDGE

Hospitalists should be able to:

• Explain the anatomy and physiology of normal and pathologic cardiac tissues, including spatial relationships, vascular supply, automaticity, conduction, and autonomic innervations and how these affect EKG interpretation.

• Compare the diagnostic utility of rhythm strips and telemetry monitors to 12‐lead EKG.

• Explain indications for ordering an EKG, including right‐sided EKG.

• Describe the implications of the acquisition, amplification, display, and standardization of electrocardiographic waveforms in different leads.

• Describe the relevant components of the EKG tracing.

• Explain the effect of cardiovascular, metabolic, toxic, and systemic disease processes on cardiac electrical potentials of the EKG.

• Explain the limitations of various EKG findings, including computerized interpretations.

SKILLS

Hospitalists should be able to:

• Demonstrate correct lead placement.

• Accurately measure and interpret the atrial and ventricular rates, voltages and intervals of EKG tracings.

• Recognize normal EKG findings, including variations associated with demographics, artifact, lead placement, and other technical problems.

• Recognize and categorize abnormal EKG findings, including abnormalities of conduction, automaticity, anatomy, and manifestations of non‐cardiac disease.

• Identify paced rhythms and describe the limitations of related EKG interpretations.

• Synthesize EKG data with other clinical information to risk stratify patients and develop a clinical plan.

ATTITUDES

Hospitalists should be able to:

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

• Personally and promptly interpret EKGs and compare them to previously recorded EKGs, when available.

• Review each EKG with a standard and consistent approach.

• Consult and collaborate with cardiologists in interpreting complex EKGs, and in ordering further diagnostic studies or procedures based on EKG interpretation.

• Determine the need for specialist intervention based on the urgency and patient risk.

SYSTEM ORGANIZATION AND IMPROVEMENT

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

• Lead, coordinate or participate in efforts to expedite acquisition and interpretation of EKGs for hospitalized patients.

Heart disease continues to be the leading cause of hospital admissions and mortality in the United States, accounting for an estimated 13% of admissions in 2001, and 21% of in‐hospital deaths in 2000. The electrocardiogram (EKG), a graphical representation of cardiac electrical potentials, is a noninvasive, readily available diagnostic tool. It remains the most commonly used investigative modality for the initial evaluation of cardiovascular disease. Hospitalists interpret these results expediently and apply the results to estimate risk, diagnose disease, and determine therapeutic needs in the hospitalized patient.

KNOWLEDGE

Hospitalists should be able to:

• Explain the anatomy and physiology of normal and pathologic cardiac tissues, including spatial relationships, vascular supply, automaticity, conduction, and autonomic innervations and how these affect EKG interpretation.

• Compare the diagnostic utility of rhythm strips and telemetry monitors to 12‐lead EKG.

• Explain indications for ordering an EKG, including right‐sided EKG.

• Describe the implications of the acquisition, amplification, display, and standardization of electrocardiographic waveforms in different leads.

• Describe the relevant components of the EKG tracing.

• Explain the effect of cardiovascular, metabolic, toxic, and systemic disease processes on cardiac electrical potentials of the EKG.

• Explain the limitations of various EKG findings, including computerized interpretations.

SKILLS

Hospitalists should be able to:

• Demonstrate correct lead placement.

• Accurately measure and interpret the atrial and ventricular rates, voltages and intervals of EKG tracings.

• Recognize normal EKG findings, including variations associated with demographics, artifact, lead placement, and other technical problems.

• Recognize and categorize abnormal EKG findings, including abnormalities of conduction, automaticity, anatomy, and manifestations of non‐cardiac disease.

• Identify paced rhythms and describe the limitations of related EKG interpretations.

• Synthesize EKG data with other clinical information to risk stratify patients and develop a clinical plan.

ATTITUDES

Hospitalists should be able to:

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

• Personally and promptly interpret EKGs and compare them to previously recorded EKGs, when available.

• Review each EKG with a standard and consistent approach.

• Consult and collaborate with cardiologists in interpreting complex EKGs, and in ordering further diagnostic studies or procedures based on EKG interpretation.

• Determine the need for specialist intervention based on the urgency and patient risk.

SYSTEM ORGANIZATION AND IMPROVEMENT

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

• Lead, coordinate or participate in efforts to expedite acquisition and interpretation of EKGs for hospitalized patients.

Heart disease continues to be the leading cause of hospital admissions and mortality in the United States, accounting for an estimated 13% of admissions in 2001, and 21% of in‐hospital deaths in 2000. The electrocardiogram (EKG), a graphical representation of cardiac electrical potentials, is a noninvasive, readily available diagnostic tool. It remains the most commonly used investigative modality for the initial evaluation of cardiovascular disease. Hospitalists interpret these results expediently and apply the results to estimate risk, diagnose disease, and determine therapeutic needs in the hospitalized patient.

KNOWLEDGE

Hospitalists should be able to:

• Explain the anatomy and physiology of normal and pathologic cardiac tissues, including spatial relationships, vascular supply, automaticity, conduction, and autonomic innervations and how these affect EKG interpretation.

• Compare the diagnostic utility of rhythm strips and telemetry monitors to 12‐lead EKG.

• Explain indications for ordering an EKG, including right‐sided EKG.

• Describe the implications of the acquisition, amplification, display, and standardization of electrocardiographic waveforms in different leads.

• Describe the relevant components of the EKG tracing.

• Explain the effect of cardiovascular, metabolic, toxic, and systemic disease processes on cardiac electrical potentials of the EKG.

• Explain the limitations of various EKG findings, including computerized interpretations.

SKILLS

Hospitalists should be able to:

• Demonstrate correct lead placement.

• Accurately measure and interpret the atrial and ventricular rates, voltages and intervals of EKG tracings.

• Recognize normal EKG findings, including variations associated with demographics, artifact, lead placement, and other technical problems.

• Recognize and categorize abnormal EKG findings, including abnormalities of conduction, automaticity, anatomy, and manifestations of non‐cardiac disease.

• Identify paced rhythms and describe the limitations of related EKG interpretations.

• Synthesize EKG data with other clinical information to risk stratify patients and develop a clinical plan.

ATTITUDES

Hospitalists should be able to:

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

• Personally and promptly interpret EKGs and compare them to previously recorded EKGs, when available.

• Review each EKG with a standard and consistent approach.

• Consult and collaborate with cardiologists in interpreting complex EKGs, and in ordering further diagnostic studies or procedures based on EKG interpretation.

• Determine the need for specialist intervention based on the urgency and patient risk.

SYSTEM ORGANIZATION AND IMPROVEMENT

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

• Lead, coordinate or participate in efforts to expedite acquisition and interpretation of EKGs for hospitalized patients.