Introduction

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

Pediatric hospitalists should be able to:

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

Pediatric hospitalists should be able to:

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

Pediatric hospitalists should be able to:

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

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

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

Introduction

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

Pediatric hospitalists should be able to:

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

Pediatric hospitalists should be able to:

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

Pediatric hospitalists should be able to:

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

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

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

Introduction

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

Pediatric hospitalists should be able to:

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

Pediatric hospitalists should be able to:

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

Pediatric hospitalists should be able to:

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

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

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

Introduction

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

Pediatric hospitalists should be able to:

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

Pediatric hospitalists should be able to:

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

Pediatric hospitalists should be able to:

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

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

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

Introduction

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

Pediatric hospitalists should be able to:

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

Pediatric hospitalists should be able to:

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

Pediatric hospitalists should be able to:

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

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

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

Introduction

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

Pediatric hospitalists should be able to:

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

Pediatric hospitalists should be able to:

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

Pediatric hospitalists should be able to:

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

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

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

Introduction

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

Pediatric hospitalists should be able to:

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

Pediatric hospitalists should be able to:

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

Pediatric hospitalists should be able to:

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

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

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

Introduction

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

Pediatric hospitalists should be able to:

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

Pediatric hospitalists should be able to:

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

Pediatric hospitalists should be able to:

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

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

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

Introduction

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

Pediatric hospitalists should be able to:

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

Pediatric hospitalists should be able to:

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

Pediatric hospitalists should be able to:

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

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

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

Introduction

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

Pediatric hospitalists should be able to:

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

Pediatric hospitalists should be able to:

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

Pediatric hospitalists should be able to:

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

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

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

Introduction

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

Pediatric hospitalists should be able to:

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

Pediatric hospitalists should be able to:

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

Pediatric hospitalists should be able to:

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

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

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

Introduction

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

Pediatric hospitalists should be able to:

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

Pediatric hospitalists should be able to:

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

Pediatric hospitalists should be able to:

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

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

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

Introduction

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

Pediatric hospitalists should be able to:

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

Pediatric hospitalists should be able to:

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

Pediatric hospitalists should be able to:

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

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

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

Introduction

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

Pediatric hospitalists should be able to:

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

Pediatric hospitalists should be able to:

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

Pediatric hospitalists should be able to:

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

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

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

Introduction

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

Pediatric hospitalists should be able to:

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

Pediatric hospitalists should be able to:

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

Pediatric hospitalists should be able to:

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

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

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

Introduction

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

Pediatric hospitalists should be able to:

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

Pediatric hospitalists should be able to:

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

Pediatric hospitalists should be able to:

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

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

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

Introduction

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

Pediatric hospitalists should be able to:

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

Pediatric hospitalists should be able to:

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

Pediatric hospitalists should be able to:

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

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

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

Introduction

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

Pediatric hospitalists should be able to:

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

Pediatric hospitalists should be able to:

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

Pediatric hospitalists should be able to:

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

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

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

Introduction

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

Pediatric hospitalists should be able to:

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

Pediatric hospitalists should be able to:

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

Introduction

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

Pediatric hospitalists should be able to:

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

Pediatric hospitalists should be able to:

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

Introduction

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

Pediatric hospitalists should be able to:

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

Pediatric hospitalists should be able to:

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

Introduction

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

Pediatric hospitalists should be able to:

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

Pediatric hospitalists should be able to:

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

Pediatric hospitalists should be able to:

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

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

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

Introduction

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

Pediatric hospitalists should be able to:

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

Pediatric hospitalists should be able to:

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

Pediatric hospitalists should be able to:

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

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

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

Introduction

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

Pediatric hospitalists should be able to:

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

Pediatric hospitalists should be able to:

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

Pediatric hospitalists should be able to:

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

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

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

Introduction

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

Pediatric hospitalists should be able to:

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

Pediatric hospitalists should be able to:

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

Pediatric hospitalists should be able to:

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

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

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

Introduction

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

Pediatric hospitalists should be able to:

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

Pediatric hospitalists should be able to:

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

Pediatric hospitalists should be able to:

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

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

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

Introduction

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

Pediatric hospitalists should be able to:

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

Pediatric hospitalists should be able to:

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

Pediatric hospitalists should be able to:

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

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

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

Introduction

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

Pediatric hospitalists should be able to:

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

Pediatric hospitalists should be able to:

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

Pediatric hospitalists should be able to:

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

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

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

Introduction

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

Pediatric hospitalists should be able to:

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

Pediatric hospitalists should be able to:

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

Pediatric hospitalists should be able to:

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

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

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

Introduction

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

Pediatric hospitalists should be able to:

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

Pediatric hospitalists should be able to:

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

Pediatric hospitalists should be able to:

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

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

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