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Individualized Learning Plan – Hospital Medicine Area of Concentration Program.

“Live as if you were to die tomorrow. Learn as if you were to live forever.” Mahatma Gandhi1

Description

Individual Learning Plan2 is a document which states your goal, outlines the plan or strategy to progress towards that goal, and records significant moments along that journey, such as an article that you have read, completed educational prescriptions3, or a specific achievement, such as getting recognition from peers or patients. There are clear curricular instructions for medicine rotation, but in an adult learning environment, you are the one driving your learning needs. The following requirements are not mandatory, but an illustration of defined strategies to accomplish your goal. There are core clinical topics, representing the minimal number that you should be proficient by the end of your PGY-2. As a PGY-3 you are expected to teach these topics to junior residents and medical students. There is an additional list of non-core subjects that you can develop similarly to the core topics to increase your longitudinal learning potential during your training.

Every clinical topic evaluates knowledge, skills, and attitudes. The monograph approach demonstrates the

ability of the resident to use the literature to document knowledge mastery. The activity log reflects the

strength of the resident to record on real cases his/her progressive mastery of his/her skills. The monograph

and activity log recommendations are available for every clinical topic. Initiatives, educational prescriptions,

and critically appraised topics demonstrate attitudes.

Definitions

1. Monograph

A written document that documents the resident effort to be up to date with the respective clinical

topic. The recommendation is to use the following guide (Combination of essentialevidenceplus.com

and NEJM resident 360)

a. Fast Facts: (Include overall bottom line, prevention, diagnoses, treatment, prognosis,

populations, and related clinical calculators)

b. Research (Landmark clinical trials and other relevant studies)

c. Reviews (Best reviews in the current literature)

d. Guidelines (Applicable current evidence-based guidelines

Complete at least two clinical topics a week during your hospital medicine rotation. Inpatient

elective and geriatric rotation offer additional time to work on the monographs. Even though the

emphasis is on hospital medicine, the topics are quite relevant to outpatient medicine.

1. Activity Log

Use the E.H.R. to create logs of clinical topics related cases that show your progression from novice to

expert. These cases not only demonstrate skills but are useful for reflective learning in studying them

from admission, discharge, and follow up in the community.

2. Initiatives/Educational Prescriptions/Critical Appraised Topics3

1 https://www.brainyquote.com/quotes/mahatma_gandhi_133995 2 https://www.gabes.ie/file/City%20of%20Galway%20VEC%20ILP%20Booklet6090.pdf 3 https://www.cebm.net/category/ebm-resources/tools/

https://www.brainyquote.com/quotes/mahatma_gandhi_133995

https://www.gabes.ie/file/City%20of%20Galway%20VEC%20ILP%20Booklet6090.pdf

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This activity is common for all the topics. It will show your practice-based learning and system based

learning activities. Use PICO to formulate answerable clinical questions and search the literature to

critically appraised each subject. Demonstrates your participation on hospital activities that denotes

you approach to master these issues.

Contents Core Clinical Conditions .......................................................................................................................................................... 3

Acute Coronary Syndrome: ..................................................................................................................................................... 3

Acute Kidney Injury ................................................................................................................................................................. 5

Alcohol and Drug Withdrawal ................................................................................................................................................ 6

Asthma .................................................................................................................................................................................... 8

Cardiac Arrhythmia ................................................................................................................................................................. 9

COPD ..................................................................................................................................................................................... 11

Community-Acquired Pneumonia......................................................................................................................................... 12

Delirium and Dementia ......................................................................................................................................................... 14

Diabetes Mellitus .................................................................................................................................................................. 16

Gastrointestinal Bleed ........................................................................................................................................................... 18

Heart Failure ......................................................................................................................................................................... 20

Hospital Acquired and Healthcare associated pneumonia ................................................................................................... 21

Hyponatremia ....................................................................................................................................................................... 23

Pain Management ................................................................................................................................................................. 24

Perioperative Medicine ......................................................................................................................................................... 26

Sepsis Syndrome ................................................................................................................................................................... 27

Skin and Soft Tissue Infections .............................................................................................................................................. 29

Stroke .................................................................................................................................................................................... 30

Syncope ................................................................................................................................................................................. 31

Urinary Tract Infection .......................................................................................................................................................... 33

Venous Thromboembolism ................................................................................................................................................... 34

Procedures ............................................................................................................................... Error! Bookmark not defined.

Thoracentesis ........................................................................................................................... Error! Bookmark not defined.

Paracentesis ............................................................................................................................. Error! Bookmark not defined.

Central Venous Cannulation .................................................................................................... Error! Bookmark not defined.

Arterial Cannulation ................................................................................................................. Error! Bookmark not defined.

Endotracheal Intubation .......................................................................................................... Error! Bookmark not defined.

Lumbar Puncture ..................................................................................................................... Error! Bookmark not defined.

Joint, Bursa, Soft Tissue Aspiration or Injection ...................................................................... Error! Bookmark not defined.

Health Care Systems Dynamics ............................................................................................................................................. 36

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Drug Safety, Pharmaco-economics, and Pharma-epidemiology .......................................................................................... 36

Equitable Allocation of Resources ........................................................................................................................................ 37

Leadership ............................................................................................................................................................................. 38

Management Practices ......................................................................................................................................................... 38

Medical Consultation and Co-management ......................................................................................................................... 39

Nutrition and the Hospitalized Patient ................................................................................................................................. 39

Palliative Care........................................................................................................................................................................ 41

Patient Handoff ..................................................................................................................................................................... 42

Patient Safety ........................................................................................................................................................................ 43

Prevention of Healthcare-associated Infections and Antimicrobial Resistance ................................................................... 44

Quality Improvement ............................................................................................................................................................ 45

Team Approach to Multidisciplinary Care ............................................................................................................................ 45

Transitions of Care ................................................................................................................................................................ 46

Initiatives/Educational Prescriptions/Critical Appraised Topics: Use a narrative form to describe if any participation or

activity. .................................................................................................................................................................................. 46

Non-Core Topics ....................................................................................................................... Error! Bookmark not defined.

Core Clinical Conditions

Acute Coronary Syndrome:

• Acute coronary syndrome (ACS) encompasses a spectrum of ischemic heart disease that may include unstable angina (UA), Non-ST-segment elevation myocardial infarction (NSTEMI), and ST-segment elevation myocardial infarction (STEMI).

• Coronary artery disease (CAD) is the leading cause of mortality in the United States and accounts for 1 in 6 deaths annually.

• Each year, approximately 635,000 Americans have ACS, and 300,000 have a recurrent event.

• Of persons who experience a coronary event or myocardial infarction, approximately 34% and 15%, respectively, will die.

• More than 45% of patients with symptoms of acute myocardial infarction arrive at the hospital 4 or

more hours after symptom onset, and the mortality rate increases for every 30 minutes that elapse

before a patient with ACS is diagnosed and treated.

• A shorter time to intervention leads to improved outcomes. If patients survive the acute stage of myocardial infarction, they have a risk of illness and mortality that is 1.5 to 15 times higher than that of

the general population.

• Annually in the United States, the number of hospital discharges with a primary or secondary diagnosis

of ACS approaches 1.2 million.

Monograph

a. Select a reference (or multiple) that address this topic. Cite here:

b. Use your references to describe/define/explain:

i. Define and differentiate UA, NSTEMI, and STEMI.

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ii. Describe the pathophysiologic processes and variable clinical presentations of patients

with ACS

iii. Distinguish ACS from other cardiac and noncardiac conditions that may mimic this

disease process.

iv. Describe the use of cardiac biomarkers in the diagnosis of ACS, including the timing of

testing and the effects of renal disease and other conditions (such as pulmonary

embolism or sepsis) on cardiac biomarker levels.

v. Describe the role of noninvasive cardiac tests in the diagnosis and management of ACS.

vi. Explain indications for and risks associated with cardiac catheterization.

vii. Recognize indications fo r early specialty consultation, which may include cardiology

and cardiothoracic surgery.

viii. List the major and minor risk factors predisposing patients to CAD.

ix. Explain the value and use of validated risk stratification tools

x. Explain indications for hospitalization of patients with chest pain.

xi. Explain indications and contraindications for fibrinolytic therapy.

xii. Explain indications, contraindications, and mechanisms of action of pharmacologic

agents that are used both upstream and downstream to treat ACS.

xiii. Describe factors that indicate the need for early invasive interventions, including

angiography, percutaneous coronary intervention, and/or coronary artery bypass

grafting.

xiv. Describe the optimal timeframe for coronary reperfusion when indicated.

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

xvi. Recognize appropriate timing and thresholds for hospital discharge, including specific

measures of clinical stability for safe transition of care.

Activity Log Log (Suggest Creating a Cerner Patient List: Cardiovascular) – Drop cases that illustrate your progress and ability to manage ACS without supervision. Use the following list to match your cases.

A. Document cases where you were directly involved and illustrate the following situations: a. A relevant history with emphasis on presenting symptoms and patient risk factors for coronary

artery disease (CAD) b. Physical examination with emphasis on the cardiovascular and pulmonary systems and

recognize clinical signs of ACS and illness severity c. Cases that you diagnosed as ACS through interpretation of expedited testing, including history,

physical examination, electrocardiogram, chest radiograph, and biomarkers. d. Cases that you performed early risk stratification using validated risk stratification tools. e. Cases that you summarized/synthesized results of history, physical examination,

electrocardiography, laboratory and imaging studies, and risk stratification tools to determine therapeutic options, formulate an evidence-based treatment plan, and assess the level of care required.

f. Patients that you ident i f ied that may benefit from fibrinolytic therapy and/or early revascularization promptly, and activated appropriate teams accordingly.

g. Cases showing your ability to treat their symptoms of chest pain, anxiety, and other discomfort associated with ACS.

h. Cases where you initiated promptly indicated therapies when patients display symptoms and signs of decompensation.

i. Cases where you anticipated and addressed factors that may complicate ACS or its management, which may include inadequate response to therapies, hemodynamic and cardiopulmonary compromise, life-threatening cardiac arrhythmias, or bleeding

j. Cases with suspected ACS that you assessed promptly, identify the level of care required and manage or co-manage the patient with the cardiology team

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k. Cases where you documented discussions with patients and families to explain the history and prognosis of their cardiac disease, explain tests and procedures and their indications and to obtain informed consent. Include other discussions such as the use and potential adverse effects of pharmacologic agents.

l. Cases documenting your discharge planning developed early during hospitalization. m. Cases showing educating patients and families about goals of care, discharge instructions, and

management after hospital discharge to ensure safe follow-up and transition of care. n. Cases where you initiated secondary preventive measures before discharge, which may include

smoking cessation, dietary modification, and evidence-based medical therapies. o. Include discharge summaries stating the notable events of the hospitalization and post-

discharge needs including outpatient cardiac rehabilitation. p. Cases documenting that you provided and coordinated resources to ensure a safe transition

from the hospital to arranged follow-up care. May include patients from your SARAH clinic (Safe Recovery After Hospitalization Program to reduce readmissions)

Acute Kidney Injury

• Acute kidney injury (AKI), also known as acute renal failure (ARF), is a decline in renal function over a period of hours or days that results in the accumulation of nitrogenous waste products and an impaired ability to maintain fluid/ electrolyte/acid-base homeostasis.

• Inconsistent definitions and underreporting confound epidemiologic studies of AKI.

• The average incidence is estimated to be 23.8 cases per 1000 hospital discharges

• Approximately 5% to 20% of critically ill patients experience AKI during the duration of their illness

• AKI may present in isolation, develop as a complication of another comorbid disease, or result as a deleterious adverse effect of treatment or diagnostic interventions

• Uncomplicated AKI is associated with a mortality rate of up to 10%.

• Patients with AKI and multiorgan failure have mortality rates higher than 50%.

• AKI is associated with an increased length of hospital stay; a rise in serum creatinine of 0.5 mg/dL or greater while hospitalized confers a 3.5-day increase in t h e length of stay

• Residents knowledgeable on AKI facilitate the quick evaluation and management of AKI to improve patient outcomes, optimize resource use, and reduce the length of stay. Residents can also advocate and initiate preventive strategies to reduce the incidence of secondary AKI.

Monograph a. Select a reference (or multiple) that address this topic. Cite here:


i. Symptoms and signs of AKI

ii. Differentiate pathophysiologic causes of AKI including prerenal, intrinsic renal, and post-

renal processes.

iii. Differentiate among the causes of prerenal, intrinsic renal and postrenal types of AKI.

iv. Describe a logical sequence of indicated tests required to evaluate etiologies of AKI

based on the classification of AKI type.

v. List common potentially nephrotoxic a g e n t s that c a n cause or worsen AKI.

vi. Explain the indications, contraindications, a n d mechanisms of action of the

interventions used to treat AKI.

vii. Explain the indications, contraindications, benefits, and risks of acute hemodialysis.

viii. Recognize indications for specialty consultation for AKI and the role of Nephrology

and/or urology specialists.

ix. Describe criteria, including specific measures of clinical stability that must be met

before discharging patients with AKI.

x. Explain the specific goals that should be met to ensure safe transitions of care for patients

with AKI.

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Activity Log Log (Suggest Creating a Cerner Patient List: AKI) – Drop cases that illustrate your progress and ability to manage AKI without supervision. Use the following list to match your clinical cases.

A. Document cases where you were directly involved and illustrate the following situations: a. Cases that you assessed with suspected AKI promptly and manage or co-manage b. Cases showing you elicited a thorough and relevant medical history with emphasis on factors

predisposing or contributing to the development of AKI c. Cases showing you reviewed all drug use including prescription and over-the-counter

medications, herbal remedies, nutritional supplements, and illicit drugs to identify common potential nephrotoxins.

d. Cases where you performed a physical examination to assess volume status and to identify underlying comorbid states that may predispose to the development of AKI.

e. Cases showing that you ordered and interpreted results of indicated diagnostic studies that may include urinalysis and microscopic sediment analysis, urinary diagnostic indices, urinary protein excretion, serologic evaluation, and renal imaging

f. Cases showing your interpretation of common clinical, laboratory, and imaging findings used to evaluate and follow the severity of AKI.

g. Cases showing how you diagnosed common complications, such as electrolyte abnormalities, that occur with AKI and institute corrective measures.

h. Cases showing you calculated or considered the estimated creatinine clearance for medication dosage adjustments when indicated.

i. Cases showing your ability to identify patients at risk for developing AKI and institute appropriate preventive measures including avoidance of unnecessary radiographic contrast exposure and adherence to evidence-based interventions to reduce the risk of contrast-induced nephropathy.

j. Cases showing your ability coordinate appropriate nutritional and metabolic interventions. k. Cases showing how you formulated an AKI treatment plan tailored to the individual patient,

which may include fluid management, pharmacologic agents, nutritional recommendations, and patient education.

l. Cases showing how you identified and treated factors that may complicate the management of AKI, including extreme blood pressure, underlying infections, and the sequelae of electrolyte abnormalities.

m. Cases showing how you communicated with patients and families to explain: i. cause and prognosis of AKI

ii. the rationale for the use of radiographic tests and procedures and the benefit and potential adverse effects of radiographic contrast agents

iii. goals of care iv. discharge instruction v. management after hospital discharge to ensure safe follow-up and transitions of care

n. Cases showing how you facilitated discharge planning early during hospitalization o. Cases documenting the treatment plan and provide clear discharge instructions for primary care

clinicians may include SARAH patients.

Alcohol and Drug Withdrawal

• Alcohol and drug withdrawal is a set of signs and symptoms that develop in association with sudden cessation or reduction in the use of alcohol or some prescription (particularly opioids and benzodiazepines), over-the-counter (OTC), or illicit drugs.

• Withdrawal syndromes encompass a broad range of symptoms from mild anxiety and tremulousness to more severe manifestations such as delirium tremens, which occurs in up to 5% of alcohol-dependent persons who undergo withdrawal

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• Withdrawal may occur before hospitalization or during the duration of hospitalization

• Alcohol- and substance-related disorders account for more than 400,000 hospital discharges each year and are associated with a mean length of stay of approximately 4.6 days

• Alcohol and drug dependence is often an end product of a combination of biopsychosocial influences, and in most cases, a multidisciplinary approach is necessary to treat affected individuals successfully

• Residents are encouraged to participate in the development of institutional evidence-based treatment protocols that improve care, reduce costs and length of stay, and facilitate better overall outcomes in patients with substance-related withdrawal syndromes.



i. Effects of drug and alcohol withdrawal on medical illness and the impact of medical

disease on substance withdrawal

ii. Symptoms and signs of alcohol and drug withdrawal, including c l i n i c a l

withdrawal from prescription and OTC drugs

iii. Recognition of medical complications from substance use and dependence.

iv. Determine when consultation with a medical toxicologist or expert is necessary.

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

vi. Differentiate delirium tremens from other alcohol withdrawal syndromes.

vii. Differentiate the clinical manifestations of alcohol or drug intoxication from those of

withdrawal.

viii. Recognize different characteristic withdrawal syndromes, such as abstinence

syndrome of opioid withdrawal and delirium tremens of alcohol withdrawal.

ix. Describe the tests indicated to evaluate alcohol or drug withdrawal.

x. Identify patients at increased risk for drug and alcohol withdrawal according to

current diagnostic criteria.

xi. Explain indications, contraindications, and mechanisms of action of pharmacologic

agents used to treat acute alcohol and drug withdrawal.

xii. Identify local trends in illicit drug use.

xiii. Determine the best setting within the hospital to initiate, monitor, evaluate, and treat patients

with drug or alcohol withdrawal

xiv. Explain patient characteristics that portend a poor prognosis.

xv. Explain patient c h a r a c t e r i s t i c s that i n d i c a t e a requirement for a higher level of

care and/or monitoring.

xvi. Explain goals for hospital discharge, including specific measures of clinical stability

for safe care transitions.

Activity Log Log (Suggest Creating a Cerner Patient List: ETOH –Drug Withdrawal) – Drop cases that illustrate your progress and ability to manage ETOH-DRUG WITHDRAWAL without supervision. Use the following list to match your clinical cases.

A. Document cases where you were directly involved and illustrate the following situations: a. Cases showing that you elicited a thorough and relevant medical history, with emphasis on

substance use. b. Cases showing how you assessed patients with suspected alcohol or drug withdrawal promptly,

identify the level of care required and manage or co-manage the patient c. Cases showing you performed a rapid, efficient, and targeted physical examination to assess

for alcohol or drug withdrawal and determine whether life-threatening comorbidities are present

d. Cases showing you evaluated for common comorbidities in patients with a history of alcohol and drug use.

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e. Cases showing how you formulated a treatment plan tailored to the individual patient, which may include appropriate pharmacologic agents and dosing, route of administration, and nutritional supplementation.

f. Cases showing how you integrated existing literature and federal regulations into the management of patients with opioid withdrawal syndromes. For patients who are undergoing current treatment for opiate dependency, communicate with outpatient treatment centers and integrate dosing regimens into care management.

g. Cases showing how you managed withdrawal syndromes in patients with concomitant medical or surgical issues.

h. Cases showing how you diagnosed over-sedation and other complications associated with withdrawal therapies.

i. Cases when you recommended the use of restraints and direct observation to ensure patient safety when appropriate

j. Cases showing how you reassured, reoriented, and frequently monitor patients in a calm environment

k. Cases where you use the acute hospitalization as an opportunity to counsel patients about abstinence, recovery, and the medical risks of drug and alcohol use.

l. Cases where you initiated preventive measures before discharge, including alcohol and drug cessation measures.

m. Cases showing how you facilitated discharge planning early in the hospitalization, including communicating with the primary care provider and presenting the patient with contact information for follow-up care, support, and rehabilitation.

n. Cases showing evidence of how you communicated with patients and families to explain the goals of care, discharge instructions, and management after hospital discharge to ensure safe follow-up and transition of care.

Asthma

• Asthma is a chronic disease characterized by airway inflammation and reversible airflow limitation.

• It is one of the most common chronic conditions, and it leads to marked morbidity and mortality in hospitalized patients.

• In the United States, 1 in 12 persons has asthma, and nearly 50% of affected individuals experience an asthma exacerbation each year, accounting for 1.8 million emergency department visits.

• Annually, more than 400,000 hospital discharges occur with asthma as the primary diagnosis, with an average length of stay of 3.2 days

• Well trained residents are central to the provision of care for patients with asthma through the use of evidence-based approaches to manage acute exacerbations and to prevent their recurrence.

• Residents should strive to lead or participate in multidisciplinary teams to develop institutional guidelines and/or care pathways to improve efficiency and quality of care and to reduce readmission rates and morbidity and mortality from asthma.

Monograph a. Select a reference (or multiple) that address this topic. Cite here: b. Use your references to describe/define/explain

a. Define asthma and describe the pathophysiologic processes that lead to reversible airway obstruction and inflammation.

b. Identify precipitants of asthma exacerbation, including environmental and occupational exposures.

c. Recognize the clinical presentation of asthma exacerbation and differentiate it from other acute respiratory and non-respiratory syndromes.

d. Describe the role of diagnostic testing, including peak flow monitoring, used for evaluation of asthma exacerbation.

e. Recognize indications for specialty consultation, including pulmonary and allergy medicine.

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f. Describe evidence-based therapies for the treatment of asthma exacerbations, which may include bronchodilators, systemic corticosteroids, and oxygen.

g. Explain indications, contraindications, and mechanisms of action of pharmacologic agents used to treat asthma.

h. Recognize signs and symptoms of impending respiratory failure. i. Explain the indications for invasive and noninvasive ventilatory support. j. List the risk factors for disease severity and death from asthma. k. Explain goals for hospital discharge, including specific measures of clinical stability for

safe care transition. Activity Log Log (Suggest Creating a Cerner Patient List: Asthma) or regular folder– Drop cases that illustrate your progress and ability to manage ASTHMA without supervision. Use the following list to match your clinical cases.

A. Document cases where you were directly involved and illustrate the following situations: a. Cases showing that you elicited a thorough and relevant medical history to identify triggers of

asthma and symptoms consistent with asthma exacerbation b. Cases showing that you performed a targeted physical examination to elicit signs consistent

with asthma exacerbation, differentiate findings from those of other mimicking conditions, and assess illness severity.

c. Cases showing that you selected appropriate diagnostic studies to evaluate the severity of asthma exacerbation and interpret the results

d. Cases showing that you recognized indications for transfer to the intensive care unit, including impending respiratory failure, and coordinated intubation or noninvasive mechanical ventilation when indicated.

e. Cases showing that you prescribed appropriate evidence-based pharmacologic therapies during asthma exacerbation, r e c o m m e n d i n g the most appropriate route, dose, frequency, and duration of treatment.

f. Cases documenting that you communicated with patients and families to: i. Explained the natural history and prognosis of asthma

ii. Facilitated discharge planning early during hospitalization. iii. Developed an asthma action plan in preparation for discharge. iv. Education regarding the indications and appropriate use of daily use inhalers and

rescue inhalers for asthmatic control. v. Explained symptoms and signs that should prompt new medical attention.

vi. Explained the goals of care, including clinical stability criteria, the importance of preventive measures (such as smoking cessation, avoidance of second-hand smoke, appropriate vaccinations, and modification of environmental exposures), and required follow-up care.

vii. Explained discharge medications, potential adverse effects, duration of therapy and dosing, and taper schedule.

g. Cases showing that you ensured that patients received training of proper inhaler and peak flow techniques before hospital discharge.

h. Cases documenting the treatment plan and provide clear discharge instructions for post-discharge clinicians.

i. Cases showing that you provided and coordinated resources to ensure safe transition from the hospital to arranged follow-up care. Use SARAH patients.

Cardiac Arrhythmia

• Cardiac arrhythmias are a group of conditions characterized by an abnormal heart rate or rhythm.

• These are common and affect approximately 5% of the population in the United States

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• More than 250,000 Americans die each year of sudden cardiac arrest, and most cases are thought to be due to ventricular fibrillation or ventricular tachycardia

• Several cardiac arrhythmias can cause instability, prompting hospitalization, or they may result from complications during hospitalization

• Annually, more than 740,000 hospital discharges are associated with a primary diagnosis of cardiac arrhythmia

• Residents should identify and treat all types of arrhythmias, coordinate specialty and primary care resources, and transition patients safely and cost-effectively through the acute hospitalization and into the outpatient setting.


a. Identify and differentiate the common clinical presentations of both benign and pathologic arrhythmias.

b. Causes of atrial and ventricular arrhythmias. c. Indicated tests required to evaluate arrhythmias. d. Explain how medications, metabolic abnormalities, and medical comorbidities may

precipitate various arrhythmias. e. Explain indications, contraindications, and mechanisms of action of pharmacologic

agents used to treat cardiac arrhythmias. Discuss the management options and goals for patients hospitalized with arrhythmias.

f. Describe the patient characteristics and comorbid conditions that predict outcomes in patients with arrhythmias.

g. Recognize indications for specialty consultation, which may include cardiology and cardiac electrophysiology.

h. Explain goals for hospital discharge, including specific measures of clinical stability for safe care transitions.

i. Recall appropriate indications for both initiation and discontinuation of continuous telemetry monitoring in the hospitalized patient.

Activity Log Log (Suggest Creating a Cerner Patient List: Arrhythmias) or regular folder– Drop cases that illustrate your progress and ability to manage ACS without supervision. Use the following list to match your clinical cases.

A. Document cases where you were directly involved and illustrate the following situations: a. Cases showing that you elicited a thorough and relevant medical history, including medications,

family history, and social history. b. Cases showing you performed a targeted physical examination with emphasis on identifying signs

associated with hemodynamic instability, tissue perfusion, and occult cardiac and vascular disease. c. Cases showing how you identified common benign and pathologic arrhythmias on

electrocardiography, rhythm strips, and continuous telemetry monitoring. (Copy and retain EKG’s tracings with your interpretation)

d. Cases showing how you determined the appropriate level of care required based on risk stratification of patients with cardiac arrhythmias.

e. Cases showing how you identified and prioritized high-risk arrhythmias that require urgent intervention and implement emergency protocols as indicated

f. Cases showing how you formulated patient-specific and evidence-based care plans incorporating diagnostic findings, prognosis, and patient characteristics.

g. Cases showing how you developed patient-specific care plans that may include rate-controlling interventions, cardioversion, defibrillation, or implantable medical devices.

h. Cases showing how you communicated with patients and families to explain i. The natural history and prognosis of cardiac arrhythmias

ii. Explanation of tests and procedures and their indications and to obtain informed consent.

iii. Explanation of drug interactions for antiarrhythmic drugs and the importance of strict adherence to medication regimens and laboratory monitoring.

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iv. Explanation of the goals of care, discharge instructions, and management after hospital discharge to ensure safe follow-up and transitions of care.

i. Cases showing how you facilitated discharge planning early during hospitalization j. Cases showing how you documented the treatment plan and provided clear discharge instructions

for PCPs. Use SARAH patients.

COPD

• Chronic obstructive pulmonary disease (COPD) is a heterogeneous group of respiratory conditions, predominantly composed of chronic bronchitis and emphysema

• COPD is defined by airflow limitation that is not entirely reversible, and it is associated with an abnormal airway inflammatory response

• Exposure to tobacco smoke is the leading risk factor

• COPD affects more than 12 million Americans and is the third leading cause of death in the United States

• A COPD exacerbation is defined as an increase in the usual symptoms of COPD that is beyond day-to-day variations and leads to a change in medication and often results in hospitalization.

• Annually, more than 670,000 hospital discharges occur with COPD as the primary diagnosis, and nearly 1 of every five hospitalized patients 40 years or older have COPD

• The average length of stay is 4.3 days

• COPD is a substantial cause of disability and carries a significant economic burden, accounting for almost $17 billion of total hospital charges billed to Medicare each year

• The early detection and prompt treatment of exacerbations are essential to ensure optimal outcomes and to reduce the burden of COPD.

• Residents use evidence-based approaches to optimize care, and they should strive to lead multidisciplinary teams to develop institutional guidelines and/or care pathways to reduce readmission rates and mortality from COPD exacerbations.


a. Define COPD and describe the pathophysiologic processes that lead to small airway obstruction and alveolar destruction.

b. Describe potential precipitants of exacerbation, including both infectious and noninfectious etiologies.

c. Differentiate the clinical presentation of a COPD exacerbation from asthma, heart failure, and other acute respiratory and non-respiratory syndromes

d. List the indicators of disease severity. e. Describe the role of diagnostic testing used for the evaluation of COPD. f. Describe the role of pulmonary function tests in the treatment of a COPD exacerbation. g. Distinguish the medical management of patients with COPD exacerbations from that

of patients with stable COPD. h. Recognize indications for specialty consultation, which may include pulmonary

medicine. i. Describe the evidence-based therapies for t h e treatment of COPD exacerbations,

which may include bronchodilators, systemic corticosteroids, oxygen, and antibiotics. j. Identify the potential risks of supplemental oxygen therapy, including the development

of hypercarbia in patients with chronic respiratory acidosis. k. Explain indications, contraindications, and mechanisms of action of pharmacologic

agents used to treat COPD. l. Describe and differentiate the means of ventilatory support, including the use of

noninvasive positive pressure ventilation in COPD exacerbation. m. Recognize anxiety and depression as critical comorbid conditions that negatively affect

outcomes. n. Explain goals for hospital discharge, including specific measures of clinical stability for

safe care transition.

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Activity Log Log (Suggest Creating a Cerner Patient List: COPD) or regular folder– Drop cases that illustrate your progress and ability to manage COPD without supervision. Use the following list to match your clinical cases.

A. Document cases where you were directly involved and illustrate the following situations: a. Cases showing that you elicited a thorough and relevant medical history to identify symptoms

consistent with a COPD exacerbation and etiologic precipitants. b. Cases showing you performed a targeted physical examination to elicit signs consistent with a

COPD exacerbation, differentiate findings from those of other mimicking conditions, and assess illness severity.

c. Cases showing how you diagnosed a COPD exacerbation by history, physical examination, and radiographic data.

d. Cases showing how you selected and interpreted appropriate diagnostic studies to evaluate the severity of a COPD exacerbation.

e. Cases showing how you recognized symptoms, signs, and severity of impending respiratory failure and selected the indicated evidence-based ventilatory approach

f. Cases showing how you chose patients with COPD exacerbation who would benefit from the use of positive pressure ventilation and identify those in whom this intervention is contraindicated.

g. Cases showing how you prescribed appropriate evidence-based pharmacologic therapies during COPD e x a c e r b a t i o n , r e c o m m e n d i n g the most appropriate drug route, dose, frequency, and duration of treatment.

h. Cases showing how you addressed treatment preferences, including advance directives early during hospital stay; implement end-of-life decisions by patients and/or families when indicated or desired.

i. Cases showing how you evaluated COPD in perioperative risk assessment, recommended measures to optimize perioperative management of COPD, and managed postoperative complications related to underlying COPD

j. Cases that you identified with COPD who may benefit from pulmonary rehabilitation. k. Cases showing how you communicated with patients and families to

i. Explain the natural history and prognosis of COPD ii. Explain discharge medications, potential adverse effects, duration of therapy and dosing,

and taper schedule. iii. Ensure that patients receive training on proper inhaler techniques and use before

hospital discharge. iv. Explain the goals of care (including clinical stability criteria, the importance of

preventive measures), discharge instructions, and management after hospital discharge to ensure safe follow-up and transitions of care.

l. Cases showing how you facilitated discharge planning early during hospitalization. m. Cases showing you provided and coordinate resources to ensure a safe transition from the

hospital to arranged follow-up care. Use SARAH patients.

Community-Acquired Pneumonia

• Community-acquired pneumonia (CAP) is an infection of the lung parenchyma that occurs in the community or is diagnosed within 48 hours of hospital admission.

• CAP is a common and potentially life-threatening infection, and it is a leading cause of death from infectious diseases.

• Approximately 25% of persons with CAP require hospitalization, and 10% to 20% of these patients require admission to the intensive care unit

• The mortality rate ranges from about 13% in hospitalized patients to 36% in patients admitted to the intensive care unit

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• CAP is a curable condition, and an organized approach to management is likely to improve clinical results and reduce mortality.

• Pneumonia outcome measures are used to evaluate t h e performance of healthcare providers and organizations.

• Residents apply evidence-based guidelines to the management of patients hospitalized with pneumonia and lead initiatives to improve quality of care and reduce practice variability.


b. Use your references to describe/define/explain

a. Define CAP, list the likely etiologies and the signs and symptoms, and distinguish CAP

from hospital-acquired pneumonia and healthcare-associated pneumonia.

b. Describe other causes of pulmonary infiltrates on radiographic studies.

c. Describe the tests indicated to evaluate and treat CAP.

d. Explain indications for respiratory isolation.

e. Identify patients with comorbidities (such as immunocompromise, diabetes mellitus,

and extremes of age) who are at high risk of a complicated course.

f. Identify specific pathogens that predispose patients to a difficult course.

g. Recognize indications for specialty consultation.

h. Describe indicated therapeutic modalities for CAP, including oxygen therapy,

respiratory care modalities, appropriate antimicrobial selection and duration, and

other evidence-based treatments.

i. Predict patient risk for morbidity and mortality from CAP using a validated risk score.

j. Explain goals for hospital discharge, including evidence-based measures of clinical

stability for safe care transition.

k. Describe factors associated with nonresponding pneumonia.

Activity Log Log (Suggest Creating a Cerner Patient List: CAP) or regular folder– Drop cases that illustrate your progress and ability to manage CAP without supervision. Use the following list to match your clinical cases.

A. Document cases where you were directly involved and illustrate the following situations: a. Cases showing that you elicited a thorough and relevant medical history to identify symptoms

consistent with CAP and demographic factors that may predispose patients to CAP. b. Cases showing that you performed a targeted physical examination to elicit signs consistent

with CAP and differentiate it from other mimicking conditions. c. Cases showing how you ordered and interpreted laboratory, microbiologic, and radiologic

studies to confirm the diagnosis of CAP and risk stratify patients. d. Cases showing how you applied evidence-based tools (such as the Pneumonia Severity Index,

CURB-65) to triage decisions and identify factors that support the need for intensive care unit admission.

e. Cases showing you initiated empiric antimicrobials for CAP by illness severity and evidence-based national guidelines, incorporating local resistance patterns.

f. Cases showing how you formulated a subsequent treatment plan that includes narrowing antimicrobial therapies by available culture data and patient response to treatment.

g. Cases showing that you recognized the criteria for clinical stability, including the appropriate de-escalation of treatment such as transitioning from parenteral to oral antimicrobials.

h. Cases showing that you recognized and addressed complications of CAP and/or inadequate response to therapy, including respiratory failure and parapneumonic effusions.

i. Cases showing that you communicated with patients and families to i. Explain the pathophysiology and prognosis of CAP.

ii. Explain tests and procedures and their indications and to obtain informed consent. iii. Explain the use and potential adverse effects of pharmacologic agents.

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iv. Explain the goals of care (including clinical stability criteria, the importance of preventive measures such as smoking cessation), discharge instructions, and management after hospital discharge to ensure safe follow-up and transitions of care.

j. Cases that show how you facilitated discharge planning early during hospitalization. k. Cases showing how you recognized and addressed barriers to follow-up care and anticipated

post-discharge requirements. l. Cases showing documentation of the treatment plan and provide clear discharge instructions for

PCP. Use SARAH cases.

Delirium and Dementia

• Delirium is defined as an acute, transient, global disorder of cognition

• In two-thirds of cases, delirium occurs in patients with baseline vulnerability, including those with underlying dementia

• Although up to 30% of older medical patients experience delirium during hospitalization, this condition is unrecognized in nearly two-thirds of cases

• Patients with delirium experience an average increase in the length of hospital stay of 8 days and mortality rates that are twice as high as those of patients without delirium.

• Also, delirium is associated with high rates of functional and cognitive decline and skilled nursing facility placement after hospitalization

• The cost of caring for patients with delirium has a marked impact on individual patients, families, and hospital systems

• Residents should be aware of screening and prevention protocols for patients at risk for delirium, as well as in the promotion of safe treatment approaches



a. Define delirium and dementia and distinguish between them.

b. Differentiate delirium from other causes of cognitive impairment, confusion, or

psychosis.

c. Describe the indicated tests required to evaluate delirium.

d. Describe the causes of delirium in the hospital setting including environmental and

iatrogenic risk factors.

e. Identify medications known to precipitate delirium.

f. Recognize the indications for specialty consultations.

g. Describe methods for the prevention of delirium.

h. Explain indications, contraindications, and mechanisms of action of pharmacologic

agents used to treat delirium.

i. Describe non-pharmacologic therapies to manage delirium.

j. Describe the complications of delirium in the hospitalized patient.

k. Discuss the multifaceted impact that delirium has on patients and their families.

l. Explain goals for hospital discharge, including specific measures of clinical stability for

safe care transitions.

Activity Log

Log (Suggest Creating a Cerner Patient List: Delirium) or regular folder– Drop cases that illustrate your progress and ability to manage Delirium without supervision. Use the following list to match your clinical cases.

A. Document cases where you were directly involved and illustrate the following situations

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a. Cases showing how you predict a patient’s risk for the development of delirium by initial history and physical examination

b. Cases illustrating that you performed appropriate screening for delirium. c. Cases showing that you developed active strategies to reduce delirium in the hospital setting by

identifying known patient risk factors that may precipitate delirium d. Cases where you assessed patients with suspected delirium promptly, determine the level of care

required, and manage or co-manages patients with the primary requesting service. e. Cases showing that you performed a focused evaluation of the underlying etiology of delirium and

institute prompt treatment to lessen its severity. f. Cases showing how you determined the best setting within the hospital to initiate, monitor,

evaluate, and treat patients with delirium. g. Cases showing you were involved in a multidisciplinary team to develop and implement care

plans for patients with delirium. h. Cases showing that you developed an appropriate pharmacologic plan to manage delirium i. Cases showing that you developed an appropriate non-pharmacologic plan to manage delirium. j. Cases showing that you developed an appropriate management plan for patients with delirium

in the postoperative setting. k. Cases documenting an appropriate treatment plan to reduce mortality, limit the duration of

delirium and the time required controlling agitation, maintaining adequate control of delirium, addressing complications, and managing the cost of treatment.

l. Cases showing that you used a patient and family-centered approach in the care of older inpatients.

m. Cases showing that you established goals and boundaries of care with patients and their families.

n. Cases showing how you communicated with patients and families to explain the history and prognosis of delirium.

o. Cases showing how you facilitated discharge planning early in the hospitalization, including communicating with the primary care provider and presenting the patient and family with contact information for follow-up care, support, and rehabilitation.

p. Cases showing how you communicated with patients and families to explain the goals of care, discharge instructions, and management after hospital discharge to ensure safe follow-up and transitions of care.

DEMENTIA

• Dementia is defined as a chronic, often progressive, decline in cognitive function, eventually limiting daily activities

• Dementia is a common comorbidity in the hospitalized older patient

• Alzheimer disease is the most prevalent form of dementia in older patients, and it accounts for up to 80% of cases

• More than 5 million persons older than 65 years have Alzheimer disease in the United States

• Patients with dementia are at increased risk for delirium, falls, and functional decline during hospitalization

• Patients with baseline cognitive impairment have prolonged lengths of stay and complex needs after discharge

• Agitation and behavioral symptoms of dementia can be exacerbated in the hospital setting and are often difficult to manage

• Care of the patient with dementia requires that Residents engage in a multidisciplinary approach to inpatient and transitional care.

Monograph

a. Select a reference (or multiple) that address this topic. Cite here:


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a. Define delirium and dementia and distinguish between them.

b. Differentiate dementia from other causes of cognitive impairment, confusion, or

psychosis

c. Describe the indicated tests required to evaluate dementia

d. Describe the causes of potentially reversible dementias or dementia-like conditions.

e. List indications, contraindications, a n d mechanisms of action of pharmacologic

agents used to treat dementia.

f. Describe non-pharmacologic therapies to manage dementia symptoms

g. Recognize the indications for specialty consultations.

h. Describe the complications of dementia in the hospitalized patient.

i. Discuss the multifaceted impact that dementia has on patients and their families.

j. Explain goals for hospital discharge including specific measures of clinical stability

for safe care transition.

Activity Log

Log (Suggest Creating a Cerner Patient List: Dementia) or regular folder– Drop cases that illustrate your progress and ability to manage Dementia without supervision. Use the following list to match your cases.

A. Document cases where you were directly involved and illustrate the following situations a. Cases showing that you performed appropriate screening for dementia. b. Cases showing how you developed active strategies to reduce the development of delirium in

patients with dementia in the hospital setting by identifying known patient risk factors that may precipitate delirium.

c. Cases showing how you assessed patients with suspected dementia promptly, identify the level of care required and manage or co-manage patients with the primary requesting service.

d. Cases showing how you assessed patients for potentially reversible causes of dementia or dementia-like conditions. Assess severity of cognitive impairment and perform a focused evaluation of the underlying etiology of dementia when appropriate.

e. Cases showing how you determined the best setting within the hospital to initiate, monitor, evaluate, and treat patients with dementia.

f. Cases showing how you formulated and lead multidisciplinary teams to develop and implement care plans for patients with dementia.

g. Cases showing how you developed an appropriate pharmacologic plan to manage dementia. h. Cases illustrating how you developed an appropriate non-pharmacologic plan to manage

dementia i. Cases where you used a patient and family-centered approach in the care of older inpatients. j. Cases showing how you communicated with patients and families to explain the history and

prognosis of dementia. k. Cases showing that you used evidence-based methods and tools to assess patients’ medical

decision-making capacity. l. Cases showing how you defended patients’ right to autonomy when so qualified. m. Cases showing how you facilitated discharge planning early in the hospitalization, including

communicating with the primary care provider and presenting the patient and family with contact information for follow-up care, support, and rehabilitation.

n. Cases showing how you communicated with patients and families to explain the goals of care, discharge instructions, and management after hospital discharge to ensure safe follow-up and transitions of care.

Diabetes Mellitus

• Diabetes mellitus is a disease characterized by abnormal insulin production or disordered glucose metabolism and is a comorbid condition of many hospitalized patients

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• Diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) are extreme presentations of diabetes mellitus that require hospitalization

• Diabetes mellitus is present in nearly 10% of the US population, and it is more common in older adults, affecting at least 25% of persons older than 65 years

• Type 2 diabetes mellitus accounts for 90% to 95% of all diagnosed cases of diabetes in adults

• Annually, more than 700,000 hospital discharges occur with diabetes mellitus or DKA as the primary diagnosis

• Residents care for diabetic patients and optimize glycemic control in the hospital setting. They stabilize and treat DKA and HHS

• The inpatient setting provides an opportunity to institute therapies to slow disease progression, prevent disease complications, and provide diabetes education to improve quality of life and limit complications leading to readmission

• Residents use evidence-based approaches to optimize care and drive multidisciplinary teams to develop institutional guidelines or care pathways to maximize glycemic control.


a. Define diabetes mellitus and explain the pathophysiologic processes that lead to

hyperglycemia, DKA, and HHS. b. Describe the impact of hyperglycemia on immune function and wound healing. c. Describe the effect of DKA and HHS on intravascular volume status, electrolytes, and

acid-base balance. d. Describe the clinical presentation and laboratory findings of DKA and HHS. e. Describe the indicated tests to evaluate and diagnose DKA and HHS. f. Explain the physiologic stressors and medications that adversely affect glycemic control. g. Explain the precipitating factors of DKA and HSS. h. Identify the goals of glycemic control in hospitalized patients in various settings,

including critically ill and surgical patients.

i. Recognize the indications for managing DKA and HHS in an intensive care unit. j. Recognize indications for early specialty consultation, which may include

endocrinology and nutrition. k. Summarize the indications, contraindications, and mechanisms of action of

pharmacologic agents used to treat diabetes mellitus. l. Recognize features that indicate disease severity. m. Recognize the impact of suboptimal glycemic control on other concurrent medical

conditions and illness. n. Explain goals for hospital discharge, including specific measures of clinical stability for

safe care transition

Activity Log

Log (Suggest Creating a Cerner Patient List: Diabetes) or regular folder– Drop cases that illustrate your progress and ability to manage DIABETES without supervision. Use the following list to match your cases.

A. Document cases where you were directly involved and illustrate the following situations a. Cases showing how you elicited a thorough and relevant medical history and reviewed the

medical record to identify factors that can affect glycemic control b. Cases showing how you estimated the level of previous glycemic control, adherence to

medication regimen, and social influences that may affect the quality of glycemic control in hospitalized patients.

c. Cases showing that you performed a comprehensive physical examination to identify possible precipitants of hyperglycemia, DKA, or HHS.

d. Cases showing how you selected and interpreted indicated studies in patients suspected of having DKA or HHS, including relevant metabolic and acid-base measurements

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e. Cases showing how you developed an individualized management plan for patients with controlled and uncontrolled diabetes mellitus, DKA, HHS, and any associated complications.

f. Cases showing how you adjusted medications and dosages to achieve optimal glycemic control and minimize adverse effects.

g. Cases that show how you evaluated and treated the signs and symptoms of hypoglycemia (especially neuroglycopenia).

h. Cases illustrating how you directed the perioperative management of the diabetic patient, and when necessary, manage or co-manage the patient with other specialties

i. Cases representing how you assessed caloric and nutritional needs and recommended a suitable diet.

j. Cases illustrating how you assessed hospitalized patients for undiagnosed diabetes mellitus. k. Cases where you recognized and addressed the effects of various diabetic complications such as

neuropathic pain. l. Cases showing how you communicated with patients and families to:

i. Explain the natural history and prognosis of diabetes mellitus. ii. Explain potential long-term complications of diabetes mellitus and preventive strategies,

including foot and eye care. iii. Explain the importance of glycemic control and factors that affect it such as adhering to

medication regimens and self-monitoring, following dietary and exercise recommendations, and attending routine follow-up appointments.

iv. Explain the potential adverse effects or adverse interactions of diabetes medications, including hypoglycemia

v. Explain the goals of care, discharge instructions, and management after hospital discharge to ensure safe follow-up and transitions of care

m. Cases that show how you facilitated discharge planning early in the admission process. n. Cases showing how you recommended appropriate post-discharge care, which may include

endocrinology, ophthalmology, and podiatry. o. Cases showing how you documented the treatment plan and provided clear discharge

instructions for post-discharge primary care physicians, including the need for continued nutrition and diabetic counseling.

Gastrointestinal Bleed

• Gastrointestinal (GI) bleed denotes any bleeding that originates in the GI tract

• Bleeding is generally defined as upper (between the mouth and the ligament of Treitz) or lower (from the ligament of Treitz to the anus)

• Acute GI bleeding complicates about 7% of all hospital stays in the United States and has an approximate 3% in-hospital mortality rate

• Annually, more than 245,000, 130,000, and 165,000 hospital discharges occur with upper GI bleed, lower GI bleed, and unspecified GI bleed as the primary diagnosis, respectively

• The degree of blood loss can vary from microscopic amounts to noticeable or massive volumes that can cause hemodynamic instability

• Between 19% and 28% of patients with GI bleeding have complications that require intensive care unit admission

• A well-orchestrated approach that includes a prompt assessment for risk stratification, evaluation for early endoscopy, initiation of pharmacotherapy, and treatment of comorbid diseases is necessary for a favorable outcome

• Residents provide immediate care for patients presenting with GI bleeding while coordinating care across multiple specialties


a. Explain the etiologies and pathophysiologic processes that lead to GI bleeds.

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

c. Describe the tests required to evaluate GI bleeds. d. Explain the risk factors for upper and lower GI bleeds and clinical indicators of patients

at high risk for complications.

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

f. Describe the approach to transfusion therapy in GI bleeds. g. Describe the treatment for concomitant coagulopathy in patients with GI bleeds. h. Compare the advantages and disadvantages of medical, endoscopic, and surgical

treatments for patients with GI bleeds. i. Explain indications, contraindications, and mechanisms of action of pharmacologic

agents used to treat GI bleeds. j. Identify clinical, laboratory, and imaging studies that indicate disease severity. k. Explain goals for hospital discharge including specific measures of clinical stability for


Activity Log

Log (Suggest Creating a Cerner Patient List: GIB) or regular folder– Drop cases that illustrate your progress and ability to manage GIB without supervision. Use the following list to match your cases.

A. Document cases where you were directly involved and illustrate the following situations a. Cases showing how you elicited a thorough and relevant history, including a directed medication,

family, and social history. b. Cases showing how you performed a physical examination to identify the likely source of

bleeding, the presence of comorbid conditions (such as liver disease), and signs of clinical instability (such as organ hypoperfusion) or complications (such as intestinal perforation).

c. Cases showing that you ordered and interpreted results of appropriate laboratory, imaging, and endoscopic tests.

d. Cases showing how you synthesized results of physical examination, laboratory testing, and imaging studies to determine the best management and care plan for the patient.

e. Cases showing how you assessed patients with GI bleeds for risk stratification and determine the corresponding level of care required.

f. Cases showing how you initiated preventive measures including avoidance of nonsteroidal anti-inflammatory agents, stress ulcer prophylaxis in critically ill patients, dietary modification, and evidence-based medical therapies.

g. Cases showing how you formulated an evidence-based treatment plan, including nutritional recommendations, pharmacologic agents, and dosing, and coordination of endoscopic and surgical interventions tailored to the individual patient.

h. Cases showing how you determined the frequency of laboratory monitoring and transfusion during hospitalization.

i. Cases that show you ensured adequate intravenous access to allow rapid volume and blood product resuscitation

j. Cases showing how you performed rapid hemodynamic resuscitation. k. Cases showing how you recognized and treated signs of clinical decompensation and recurrent

bleeding. l. Cases showing how you assessed patients with suspected GI bleeds promptly and manage or co-

manage the patient with the primary requesting service m. Cases showing how you communicated with patients and families to

i. Explain the disease etiology, prognosis, risk reduction strategies, and symptoms of recurrent GI bleed.

ii. Explain risks, benefits, and alternatives to transfusion therapy

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iii. Explain the goals of care, discharge instructions, and management after hospital discharge to ensure safe follow-up and transitions of care.

Heart Failure

• Heart failure (HF) is characterized by impaired cardiac function resulting in a constellation of symptoms that includes fatigue, weakness, and shortness of breath

• In North America, the lifetime risk of developing HF is 20% for all persons older than 40 years; more than 5 million persons have HF in the United States

• Roughly half of those who develop HF die within five years of diagnosis

• HF exacerbation is one of the most common diagnoses leading to hospital admission, and annually more than 1 million hospital discharges occur with HF as the primary diagnosis


• Direct medical costs for HF total more than $20 billion each year

• Despite published guidelines for HF management, treatment of hospitalized patients varies markedly. Monograph

a. Select a reference (or multiple) that address this topic. Cite here: b. Use your references to describe/define/explain

a. Explain underlying causes of HF and precipitating factors leading to exacerbation b. Differentiate features of systolic and diastolic dysfunction and explain the common

etiologies of each. c. Identify the clinical indications for hospitalization for acute decompensated HF. d. Describe the indicated tests required to evaluate HF including assessment of both left

and right ventricular function. e. Explain when reassessment of the left ventricular function is indicated.

f. Explain the utility and limitations of cardiac biomarkers (e.g., age adjusted). g. Explain markers of disease severity and factors that influence prognosis. h. Describe risk factors for the development of HF in the hospital setting. i. Recognize indications for an early cardiology consultation. j. Describe the goals of inpatient therapy for acute decompensated HF, including pre-load

and after-load reduction, hemodynamic stabilization, and optimization of volume status.

k. Describe the role of invasive and noninvasive ventilatory support. l. Explain evidence-based therapeutic options for management of both acute and chronic

HF and list contraindications to these therapies.

m. Explain indications, contraindications, and mechanisms of action of pharmacologic agents used to treat HF.

n. Identify medications and interventions contraindicated in HF. o. Recognize indications for device therapy (such as implanted cardioverter defibrillator,

cardiac resynchronization therapy, and left ventricular assist devices). p. Recognize indications and qualifications for cardiac trans- plant evaluation. q. Explain the importance of palliative care in the treatment of patients with chronic HF. r. Explain goals for hospital discharge including specific measures of clinical stability for


Activity Log

Log (Suggest Creating a Cerner Patient List: Heart Failure) or regular folder– Drop cases that illustrate your progress and ability to manage HEART FAILURE without supervision. Use the following list to match your clinical cases.

A. Document cases where you were directly involved and illustrate the following situation

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a. Cases showing how you elicited a thorough and relevant medical history and reviewed the medical record to identify symptoms, comorbidities, medications, and/or social influences contributing to HF or its exacerbation

b. Cases showing how you recognized the clinical presentation of HF including features of worsening and reliability of signs and symptoms.

c. Cases showing how you identified physical findings consistent with HF. d. Cases showing how you identified symptoms and signs of low perfusion states and cardiogenic

shock. e. Cases showing how you assessed patients with suspected HF promptly, identify the level of care

required, and manage or co-manage the patient with the primary requesting service. f. Cases showing that you ordered indicated diagnostic testing to identify precipitating factors of

HF and assess cardiac function. g. Cases showing how you risk-stratified patients admitted with HF and determined the appropriate

level of care. h. Cases showing how you formulated an evidence-based treatment plan tailored to the individual

patient, which may include pharmacologic agents, device implantation, nutritional recommendations, and patient adherence.

i. Cases showing how you recognized symptoms and signs of acute decompensation and initiated immediately indicated therapies.

j. Cases showing how you communicate with patients and families to i. Explain the history and prognosis of HF.

ii. Explain tests and procedures and their indications and to obtain informed consent. iii. Explain the use and potential adverse effects of pharmacologic agents iv. Explain the importance of home self-monitoring, adherence to medication regimens,

nutritional recommendations, and physical rehabilitation. v. Explain the goals of care, discharge instructions, and management after hospital

discharge to ensure safe follow-up and transitions of care. k. Cases showing how you facilitated discharge planning early during hospitalization. l. Cases showing how you communicated to outpatient providers the relevant events of the

hospitalization and post-discharge needs, including pending tests, and determine who is responsible for checking the results.

Hospital Acquired and Healthcare associated pneumonia

• Hospital-acquired pneumonia (HAP) is an infection of the lung parenchyma that occurs during hospitalization

• HAP is a significant source of morbidity, mortality, and increased resource expenditures, including prolonged hospital length of stay by an average of 7 to 9 days

• HAP accounts for approximately 15% of all hospital-acquired infections, and the associated mortality rate ranges from 20% to 50%

• The primary risk factor for the development of HAP is mechanical ventilation, and HAP occurs in 9% to 27% of all intubated patients

• Healthcare-associated pneumonia (HCAP) was added as a category of pneumonia in the 2005 American Thoracic Society/Infectious Diseases Society of America guidelines to identify patients at increased risk for multidrug-resistant pathogens coming from community settings

• HCAP is defined as pneumonia acquired in healthcare environments outside of the traditional hospital setting and is distinct from community-acquired pneumonia (CAP), HAP, or ventilator-acquired pneumonia

• HCAP more closely resembles HAP concerning pathogens and prognosis

• Quality indicators have been created around the critical processes of care for patients with pneumonia, and these indicators are used to evaluate the performance of states, healthcare organizations, physician groups, and individual physicians

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• R e s i d e n t s apply evidence-based practice guidelines to the management of patients hospitalized with pneumonia and lead initiatives to improve quality of care and reduce practice variability.

Monograph


a. Define HAP and HCAP and differentiate them from CAP. b. List of common organisms associated with HAP and HCAP. c. Describe local and national resistance patterns for HAP and HCAP. d. Identify critical historical elements, medical record data, and physical examination

findings consistent with HAP and HCAP. e. Differentiate the infectious causes of HAP and HCAP from those of CAP. f. Describe the tests required to evaluate HAP and HCAP. g. Identify risk factors for developing HAP and HCAP. h. Describe the role of mechanical ventilation as a risk factor for the development of HAP. i. Explain the prophylactic measures commonly used to lower the risk of HAP.

j. Describe steps that can be used to limit the emergence of antibiotic resistance. k. Recognize indications for specialty consultation, which may include infectious disease

and/or pulmonary services. l. Describe the role of mechanical ventilation as a potential treatment option. m. Describe infection control practices to prevent the spread of resistant organisms within

the hospital n. Describe potential complications of HAP and HCAP. o. Explain goals for hospital discharge including evidence-based measures of clinical

stability for safe care transition. p. Explain implications of HAP and HCAP on discharge planning.

Activity Log

Log (Suggest Creating a Cerner Patient List: HCAP) or regular folder– Drop cases that illustrate your progress and ability to manage HCAP without supervision. Use the following list to match your cases.

A. Document cases where you were directly involved and illustrate the following situations a. Cases showing how you elicited a thorough and relevant medical history to identify symptoms

consistent with HAP and HCAP. b. Cases showing how you performed a targeted physical examination to elicit signs consistent

with HAP and HCAP. c. Cases showing how you assessed patients with suspected HAP promptly and managed or co-

manage the patient with the primary requesting service. d. Cases showing how you ordered and interpreted laboratory, microbiologic, and radiologic studies

to confirm the diagnosis of HAP and HCAP and determine the etiologic agent. e. Cases showing how you initiated an empiric antibiotic regimen by patient history, underlying

comorbid conditions, likely organisms, and local resistance patterns. f. Cases showing how you tailored antibiotic regimens by microbiologic culture and sensitivity data

as soon as available. g. Cases showing how you managed complications of HAP and HCAP, which may include

respiratory failure, pleural effusions, and empyema. h. Cases showing how you coordinated care for patients requiring mechanical ventilation. i. Cases showing how you identified patients, who require thoracentesis, perform or coordinate the

procedure, and interpret the results. j. Cases showing how you communicated with patients and families to

i. Explain the tests, procedures, and their indications, and to obtain informed consent. ii. Explain the etiology, management plan, and potential outcomes of HAP and HCAP.

k. Cases showing how you facilitated discharge planning early during hospitalization.

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l. Cases showing how you documented the treatment plan and provided clear discharge instructions for post-discharge clinicians.

Hyponatremia

• Hyponatremia, defined as a serum sodium value less than 135 mEq/L, is the most common electrolyte disorder observed in hospitalized patients in the United States, occurring in up to 60% of patients

• The disease may develop within 48 hours of, or during, hospitalization (acute), or maybe subacute or chronic

• When it develops in the hospital, hyponatremia is associated with increased length of stay, increased the cost of hospitalization, increased in-hospital mortality, and increased post-discharge mortality.

• Even chronic hyponatremia present at hospital admission adversely affects outcomes—such patients have a 30% higher risk of mortality and are hospitalized 14% longer than patients without hyponatremia at admission

• Residents can facilitate the evaluation and management of hyponatremia to improve patient outcomes, as well as decrease healthcare costs and length of stay.


a. Distinguish acute from chronic hyponatremia. b. Identify hospitalized patients at risk of developing hyponatremia and institute

monitoring measures to increase early recognition. c. Describe the symptoms of mild and severe hyponatremia. d. Describe the indicated serum and urine laboratory tests used to evaluate the causes of

hyponatremia. e. Differentiate among hypertonic, isotonic, and hypotonic forms of hyponatremia. f. Identify the likely pathophysiologic process underlying a patient’s hyponatremia by

urine osmolality and electrolyte concentrations. g. Identify the likely pathophysiologic process underlying a patient’s hyponatremia by the

clinical volume status and urine sodium value. h. Explain how concurrent fluid administration or diuresis may affect urinary tests used

in the evaluation of hyponatremia. i. Explain the physiology leading to the development of the syndrome of inappropriate

antidiuretic hormone secretion (SIADH) and describe how it is diagnosed. j. Recognize indications for specialty consultation, such as endocrinology or nephrology. k. Describe an appropriate treatment strategy for patients with asymptomatic, mildly

symptomatic, and severely symptomatic hyponatremia, including the risks of treatment.

l. Explain the appropriate rate of correction for acute or chronic hyponatremia, adjusted to the needs of the individual patient.

m. Explain the indications for water restriction in hyponatremia. n. Explain the indications of isotonic sodium chloride fluid administration in

hyponatremia. o. Explain the indications for hypertonic sodium chloride fluid administration in

hyponatremia. p. Explain the role, limitations, risks, and contraindications of vasopressin receptor

agonists in the treatment of hyponatremia. q. Predict how concurrent correction of other electrolyte disorders (e.g., hypokalemia)

may affect sodium correction.

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Activity Log

Log (Suggest Creating a Cerner Patient List: Hyponatremia) or regular folder– Drop cases that illustrate your progress and ability to manage HYPONATREMIA without supervision. Use the following list to match your cases.

A. Document cases where you were directly involved and illustrate the following situations a. Cases showing how you elicited a thorough and relevant medical history, perform a physical

examination and review the medical record for factors contributing to the development of hyponatremia.

b. Cases showing how you accurately assessed the relevant volume status and neurologic examination findings of a patient with hyponatremia.

c. Cases showing how you ordered and interpreted indicated diagnostic studies that may include serum electrolytes, serum and urine osmolality, serum blood urea nitrogen, creatinine, uric acid, urine sodium, thyrotropin, and early-morning cortisol.

d. Cases showing how you formulated and implemented the most appropriate intervention tailored to the individual patient’s etiology of hyponatremia while minimizing potential complications from overcorrection or under-correction.

e. Cases showing how you identified the most appropriate care setting to monitor patients with hyponatremia, including indications to transfer to the intensive care unit.

f. Cases showing how you recognized symptoms and signs of severe hyponatremia and osmotic demyelination syndrome.

g. Cases showing how you communicated with patients and families to i. Explain the significance, etiology, and importance of recognizing and treating

hyponatremia. ii. Explain the risks, monitoring, and appropriate management of hyponatremia.

h. Cases showing how you documented the treatment plan and provided clear discharge instructions

i. Cases showing how you facilitated coordination of transitional monitoring of recurrent hyponatremia after hospital discharge.

Pain Management

• Pain is a very common presenting or accompanying symptom in hospitalized patients

• Pain management relies on the use of various modalities to alleviate suffering and restore patient function

• Proper assessment and treatment of pain can improve clinical outcomes, discharge planning, and patient and family satisfaction

• Managing pain in inpatients necessitates understanding the various mechanisms that cause pain, properties of analgesic pharmacologic and non-pharmacologic modalities, and accurate assessment of severity and treatment response

• Residents assess and manage patients experiencing pain. This role requires that R es id ent s be aware of current issues and controversies in pain management.

• Opioid therapy, for example, is a well-established approach for treating severe acute pain and cancer-related pain, and opioids are the most commonly prescribed drug class in the United States

• However, the continued increase in opioid prescription coincides with an increased number of poisoning deaths.

• Poisoning deaths involving opioid analgesics have more than tripled since 1999

• To best manage patients’ pain, R es id ent s must demonstrate empathy, clinical excellence, and an understanding of the obstacles, cautions, specific knowledge, skills, and attitudes necessary for appropriate pain management


a. Describe the mechanisms that cause pain.

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b. Describe the symptoms and signs of pain. c. Differentiate acute, chronic, somatic, neuropathic, referred, and visceral pain syndromes. d. Differentiate tolerance, dependence, addiction, and pseudo-addiction. e. Describe the value and limitations of the physical examination and various validated

pain intensity assessment scales.

f. Recognize indications for specialty consultation, which may include pain service, anesthesiology, and physical and rehabilitation medicine.

g. Explain the relationship among physical, cultural, and psychological factors and pain and pain thresholds.

h. Describe the indications and limitations of opioid pharmacotherapy. i. Discuss the genetic, social, and psychological factors that may contribute to opioid

addiction. j. Describe the indications and limitations of other analgesics including tramadol,

tricyclic agents, and anticonvulsant medications in the treatment of various pain syndromes.

k. Describe the indications and limitations of nonopioids including acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), and topical agents.

l. Describe specific factors that affect dosing regimens such as drug half-life, renal function, and hepatic function.

m. Describe the indications and limitations of nonpharmacologic methods of pain control available in the inpatient setting

n. Establish functional criteria for discharge.

Activity Log

Log (Suggest Creating a Cerner Patient List: Pain-Management) or regular folder– Drop cases that illustrate your progress and ability to manage PAIN MANAGEMENT without supervision. Use the following list to match your clinical cases.

A. Document cases where you were directly involved and illustrate the following situations a. Cases showing how you elicited a thorough and relevant history and description of pain and

reviewed the medical record to determine the likely source and acuity of pain. b. Cases showing how you reviewed patient pharmacologic and psychosocial history and identified

factors contributing to pain or factors that might affect its management. c. Cases showing how you performed a physical examination to determine the likely source of pain. d. Cases showing how you ordered and interpreted diagnostic studies to determine the source of

pain when the underlying acute illness is suspected e. Cases showing how you assessed pain severity using validated measurement tools f. Cases showing how you formulated an initial pain management plan. g. Cases showing how you determined the appropriate route, dosage, and frequency of dosing for

pharmacologic agents by patient-specific factors. h. Cases showing how you reassessed pain severity and determined the need for escalating therapy

and/or adjuvant therapies. i. Cases showing how you determined equianalgesic dosing for pharmacologic therapy when needed j. Cases showing how you titrated s hort- and long-acting opioids to the desired effect. k. Cases showing how you predicted and counteracted as needed, expected adverse analgesic

effects, including use of reversal and specific agents, especially in older patients. l. Cases showing how you anticipated and managed adverse effects of pain medications including

respiratory depression and sedation, nausea, vomiting, and pruritus. m. Cases showing how you initiated appropriate therapies to prevent and treat constipation when a

patient is taking opioid analgesics. n. Cases showing how you assessed and communicate the need for pain management during

medical consultation.

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o. Cases showing how you recognized the signs and symptoms of addiction and assessed patients for prescription drug abuse when appropriate.

p. Cases showing how you educated patients on i. Adverse effects of prescription drug abuse.

ii. Importance of appropriate use of opioids in pain management and explain the rarity of opioid addiction in the setting of proper pain management.

q. Cases showing how you established and maintained an open dialogue with patients and families regarding care goals and limitations, which may include palliative care and end-of-life wishes.

r. Cases showing how you documented treatment plans, provide clear discharge instructions, and communicate with the outpatient clinician responsible for follow-up to ensure a safe transition.

Perioperative Medicine

• Perioperative medicine refers to the medical evaluation and management of patients before, during, and after surgical intervention.

• Residents should participate in performing general medical preoperatively optimization, and provide postoperative medical management

• During perioperative care, Residents often identify conditions related to surgical outcomes and make relevant recommendations, such as delaying surgery so the patient’s medical condition can be optimized

• In orthopedic surgery patients, for example, the perioperative care model may be associated with shortened time to surgery, decreased the length of stay, and lower hospital costs


a. Explain the physiologic effects of anesthesia and surgery. b. Describe the goals, components, and role of cardiovascular preoperative risk

assessment. c. Describe the goals, components, and role of pulmonary preoperative risk assessment. d. Describe risk factors for perioperative cardiovascular, pulmonary, infectious,

hematologic, neurologic, venous thromboembolic, and other complications e. Identify pharmacologic therapies that may need to be modified or held before surgery

including analgesics, anti- hypertensive agents, immunosuppressive therapy, anticoagulants, and complementary/alternative medicines.

f. List widely accepted risk assessment tools and explain their value and limitations in patients undergoing non- vascular surgery.

g. Describe the evidence surrounding prophylactic perioperative interventions such as β-blockade or incentive spirometry.

Activity Log

Log (Suggest Creating a Cerner Patient List: Perioperative) or regular folder– Drop cases that illustrate your progress and ability to manage PERIOPERATIVE without supervision. Use the following list to match your cases.

A. Document cases where you were directly involved and illustrate the following a. Cases showing how you elicited a thorough history, review the medical record and inquire about

functional capacity in patients undergoing surgery. b. Cases showing how you performed a targeted physical examination focused on the

cardiovascular and pulmonary systems and other systems by patient history. c. Cases showing how you assessed pain levels in perioperative patients and make recommendations

for pain management when indicated.

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d. Cases showing how you perform a directed and cost-effective diagnostic evaluation by the patient’s relevant history and physical examination findings.

e. Cases showing how you used published algorithms and validated clinical scoring systems, when available, to assess and risk stratify patients.

f. Cases showing how you assessed the urgency of the requested evaluation and provided feedback and assessment in an appropriate timeframe.

g. Cases showing how you identified medical conditions that increase the risk for perioperative complications and make specific evidence-based recommendations to optimize outcomes in the perioperative period.

h. Cases showing how you determined the perioperative medical management strategies required to address specific disease states

i. Cases showing how you developed a comprehensive perioperative plan j. Cases showing how you initiated indicated a perioperative preventive approach k. Cases showing how you reassessed patients for postoperative complications and make medical

recommendations as indicated. l. Cases showing how you communicated with patients and families to

i. Explain the primary care physician’s role in perioperative medical care, any indicated preoperative testing related to their medical conditions or risk assessment, and any adjustment of pharmacologic therapies.

ii. Explain any indicated perioperative prophylactic measures. m. Cases showing how you facilitated discharge planning early in the hospitalization, including

communicating with the primary care provider and presenting the patient and family with contact information for follow-up care.

Sepsis Syndrome

• Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection

• Sepsis has various etiologies and clinical presentations. It accounts for substantial morbidity and mortality and is a leading cause of hospitalization in the United States

• More than 1 million hospital discharges occur with sepsis as the primary diagnosis, and the incidence continues to rise

• Sepsis is the most expensive condition treated in US hospitals, and length of stay is roughly 75% longer than it is for other conditions

• Sepsis requires expeditious diagnosis, and standardized treatment plans to influence patient morbidity and mortality favorably

• The in-hospital mortality rate for sepsis varies depending on disease severity and is approximately 16%

• Septic shock is a subset of sepsis in which underlying circulatory and cellular/metabolic abnormalities are profound enough to increase mortality substantially

• Residents have a crucial role in the early identification of patients with sepsis, and they practice evidence-based evaluation and interventions such as initial goal-directed therapy for patients with sepsis and septic shock


a. Define and differentiate sepsis and septic shock from an uncomplicated infection. b. Describe prognostic scoring tools used to assess morbidity and mortality in patients with

sepsis, such as the Sequential Organ Failure Assessment (SOFA) and Quick SOFA (qSOFA) scores, and the systemic inflammatory response syndrome (SIRS) criteria.

c. Describe the pathobiology that leads to sepsis and septic shock. d. Differentiate septic shock from other causes of shock. e. Recognize the value and limitations of the history and physical examination in

determining the cause of sepsis.

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f. Recognize the indications for specialty consultations, which may include critical care medicine.

g. Identify patient groups with increased risk for the development of sepsis, increased morbidity or mortality, or uncommon etiologic organisms.

h. Describe the elements and efficacy of early goal-directed therapy for the treatment of

sepsis and septic shock. i. Describe the mechanism of action, indications, contraindications, and adverse effects

of therapeutic agents, including intravenous fluids, vasopressors, and antimicrobials, in the treatment of sepsis.

j. Describe the indications for and limitations of central venous access and its value for hemodynamic monitoring and administration of vasoactive agents.

k. Explain patient characteristics that on admission portend a poor prognosis. l. Explain goals for hospital discharge, including specific measures of clinical stability for


Activity Log

Log (Suggest Creating a Cerner Patient List: Sepsis) or regular folder– Drop cases that illustrate your progress and ability to manage SEPSIS without supervision. Use the following list to match your cases.

A. Document cases where you were directly involved and illustrate the following situations a. Cases showing how you used all available information, including medical records and history

provided by the patient and caregivers, to identify factors that contribute to the development of sepsis.

b. Cases showing how you performed a rapid and targeted physical examination to identify potential sources of sepsis.

c. Cases showing how you ordered indicated diagnostic testing to identify the source of sepsis and determine the severity of organ dysfunction.

d. Cases showing how you rapidly identify patients with septic shock and aggressively treat in parallel with transfer to a critical care setting.

e. Cases showing how you assessed cardiopulmonary stability and implemented aggressive fluid resuscitation, airway maintenance, and circulatory support.

f. Cases showing how you measured and interpreted indicated hemodynamic monitoring parameters.

g. Cases showing how you initiated empiric antimicrobial therapy by the suspected etiologic source of infection.

h. Cases showing how you assessed the need for central venous access and monitoring; when needed, coordinate or establish central venous access.

i. Cases showing how you determined or coordinate appropriate nutritional and metabolic interventions.

j. Cases showing how you supported organ function and correct metabolic derangements when indicated.

k. Cases showing how you implemented measures to ensure optimal glycemic control. l. Cases showing how you adopted measures to prevent complications, which may include

aspiration precautions, stress ulcer and venous thromboembolism prophylaxis, and decubitus ulcer prevention.

m. Cases showing how you communicated with patients and families to i. Explain the history and prognosis of sepsis and indicators of functional improvement or

decline. ii. Explain tests and procedures and their indications and to obtain informed consent.

iii. Explain the goals of care, clinical stability criteria, discharge instructions, and management after hospital discharge

n. Cases showing how you addressed resuscitation status early during hospital stay and discuss and implement end-of-life decisions by patient or family when indicated or desired.

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Skin and Soft Tissue Infections

• Cellulitis is a bacterial infection of the skin and subcutaneous tissues

• It is a common, potentially dangerous medical condition that can result in significant morbidity and hospitalization

• Annually, more than 620,000 hospital discharges occur with skin and soft tissue infection as the primary diagnosis

• Potential complications include abscess formation

• Residents participate in efforts to standardize care delivery, promote antibiotic stewardship, improve discharge planning, and promptly identify and address severe cases of cellulitis to minimize complications and improve patient outcomes.


a. Describe the clinical presentation of cellulitis and distinguish between routine and complicated cellulitis.

b. Differentiate cellulitis from chronic venous stasis changes and other mimicking skin conditions and discuss the accuracy of common signs and symptoms in patients with suspected cellulitis.

c. Describe the tests used to evaluate cellulitis. d. Discuss possible causative organisms by classic associations with specific host exposures. e. Describe factors associated with an increased risk of worsening disease severity and

complications. f. Recognize indications for early specialty consultation in patients with complications,

misdiagnosis, or lack of response to therapy. g. Differentiate empiric antibiotic regimens for uncomplicated and complicated types of

cellulitis. h. Explain indications for outpatient treatment and need for hospital admission. i. Explain goals for hospital discharge, including specific measures of clinical stability for


Activity Log

Log (Suggest Creating a Cerner Patient List: SSTI) or regular folder– Drop cases that illustrate your progress and ability to manage SSTI without supervision. Use the following list to match your clinical cases.

A. Document cases where you were directly involved and illustrate the following situations a. Cases showing how you elicited a focused medical history to identify precipitating causes of

cellulitis and comorbid conditions that may affect clinical management. b. Cases showing how you assessed patients with cellulitis promptly and managed or co-manage

patients with the primary requesting service c. Cases showing how you accurately identified routine cellulitis borders and signs of complications,

which may include crepitus and abscess. d. Cases showing how you recommend an appropriate, cost-effective initial diagnostic evaluation of

cellulitis, including laboratory and radiologic studies. e. Cases showing how you initiated empiric antibiotic treatment of cellulitis by host exposures,

predisposing underlying systemic illness, history and physical examination findings, presumptive bacterial pathogens, and evidence-based recommendation

f. Cases showing how you treated coexisting fungal infection, edema, and other conditions that may exacerbate cellulitis.

g. Cases showing how you formulated a subsequent treatment plan that includes narrowing antibiotic therapies by available culture data and the patient’s response to treatment.

h. Cases showing how you determined the appropriate timing for the transition from intravenous to oral therapy and duration of antibiotic treatment.

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i. Cases showing how you initiated preventive measures for minimizing the risk of recurrent cellulitis.

j. Cases showing how you communicated with patients and families to i. Explain the history and prognosis of cellulitis.

ii. Explain tests and procedures and their indications and to obtain informed consent. iii. Explain the goals of care, discharge instructions, and management after hospital

discharge to ensure safe follow-up and transitions of care k. Cases showing how you facilitated discharge planning early during hospitalization. l. Cases showing how you documented the treatment plan and provided clear discharge

instructions for post-discharge primary care physicians

Stroke

• Stroke is defined as damage to brain tissue resulting from an interruption in blood flow

• This condition accounts for significant morbidity and mortality in hospitalized patients

• Annually in the United States, approximately 1 million hospital discharges occur with cerebrovascular disease as the primary diagnosis


• Stroke care is a rapidly evolving field in which prompt and careful inpatient care significantly affect the outcome. For example, intravenous thrombolytic therapy administered within the recommended time window from symptom onset is associated with more favorable results

• Therefore, it is incumbent on Residents to develop the knowledge and skills to identify and manage strokes, coordinate specialty and primary care resources, and guide patients safely through the acute hospitalization and back into the outpatient setting.


a. Describe causes of ischemic and hemorrhagic stroke. b. Describe the relationship between the anatomic location of stroke and clinical

presentation. c. List risk factors for ischemic and hemorrhagic stroke. d. Describe appropriate imaging techniques and laboratory testing to evaluate patients

with suspected stroke. e. Recognize the indications for early specialty consultation, which may include neurology,

neurosurgery, and interventional radiology. f. Describe indications, contraindications, and mechanisms of action of pharmacologic

agents used to treat stroke. g. Describe indications and contraindications for thrombolytic therapy in the setting of

acute stroke. h. Explain blood pressure control strategies for patients presenting with different types of

stroke. i. List indications for early surgical and endovascular interventions. j. Explain the spectrum of functional outcomes of different types of stroke and how these

relate to the initial presentation. k. Explain goals for hospital discharge, including specific measures of clinical stability for


Activity Log

Log (Suggest Creating a Cerner Patient List: Stroke) or regular folder– Drop cases that illustrate your progress and ability to manage STROKE without supervision. Use the following list to match your cases.

A. Document cases where you were directly involved and illustrate the following

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a. Cases showing how you elicited a thorough and relevant medical history to assess for symptoms that are typical of stroke

b. Cases showing how you performed an appropriate physical examination to diagnose stroke and to help guide further management.

c. Cases showing how you assessed patients with stroke promptly. d. Cases showing how you diagnosed the etiology of stroke through interpretation of initial testing

including history, physical examination, electrocardiogram, neurologic imaging, and laboratory results.

e. Cases showing how you initiated indicated acute therapies to improve the prognosis of stroke f. Cases showing how you identified patients at risk for acute decompensation, which may include

those with signs of increased intracranial pressure and posterior circulation disease. g. Cases showing how you identified patients at risk for aspiration following stroke and address

nutritional issues. h. Cases showing how you managed the airway, temperature, blood pressure, and glycemic status of

patients with stroke when indicated. i. Cases showing how you addressed resuscitation status early during hospital stay; implemented end-

of-life decisions by patients and/or families when indicated or desired j. Cases showing how you initiated prophylaxis against common complications, which may include

urinary tract infection, aspiration pneumonia, and venous thromboembolism k. Cases showing how you started secondary stroke prevention. l. Cases showing how you communicate with patients and families to

a. Explain the history and prognosis of stroke b. Explain the tests and procedures and their indications and to obtain informed consent. c. Explain the use and potential adverse effects of pharmacologic agents. d. Explain the goals of care, discharge instructions, and management after hospital discharge to

ensure safe follow-up and transitions of care. m. Cases showing how you recognized barriers to follow-up care of patients who have had a stroke and

involve multidisciplinary hospital staff to accordingly tailor medications and transition of care plans. n. Cases showing how you documented the treatment plan and provided clear discharge instructions for

post-discharge clinicians, which may include outpatient rehabilitation.

Syncope • Syncope is defined as a transient loss of consciousness that results from cerebral hypoperfusion • Characteristically, it is abrupt in onset, short-lived, and resolves spontaneously • Presyncope is a term used to describe a near-syncopal event involving identical pathophysiology as

syncope; however, the patient does not fully lose consciousness • Syncope affects approximately 1 million Americans every year and accounts for 6% of all hospital

admissions • Nearly 1 in 3 persons will experience a syncopal event at least once in their lifetime • The condition reflects the end-point of myriad processes ultimately leading to a disruption in the

oxygen supply to the brain • Systemic hypotension accompanied by cerebral hypoperfusion most commonly causes it. • Syncope-related mortality varies depending on the etiology and is higher in persons with the

underlying cardiovascular disease • Although many etiologies of syncope are self-limited and benign, Residents must be able to identify

patients who may have serious underlying conditions, as well as those at high risk for complications from a syncopal event

• Residents should evaluate whether diagnostic tests are indicated and curtail their routine use in patients with simple syncope for whom there is little clinical value

• Furthermore, Residents must balance the tempo and depth of an inpatient evaluation to safely assess patients before effectively transitioning them to the outpatient environment

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a. Define syncope. b. Differentiate syncope from other causes of loss of consciousness, such as seizure. c. Explain the physiologic mechanisms that lead to reflex or neurally mediated syncope. d. Identify common causes of neurally mediated syncope such as neuro-cardiogenic,

carotid sinus, and situational syncope. e. Identify conditions associated with orthostatic hypotension that may result in syncope. f. Identify medications that may contribute to, or cause, syncope. g. Identify common cardiac etiologies for syncope, including structural heart disease or

dysrhythmia. h. Identify unusual pulmonary or vascular etiologies for syncopes, such as pulmonary

embolism or vertebrobasilar insufficiency. i. Recognize associated metabolic conditions that may trigger loss of consciousness such as

hypoglycemia. j. Describe risk factors that place patients at higher risk for poorer outcomes and/or

complications secondary to syncope. k. List the indications that require inpatient evaluation of syncope. l. Recognize indications for specialty consultation, such as cardiology or neurology. m. Outline an evidence-based strategic process to evaluate patients with syncope.

Activity Log

Log (Suggest Creating a Cerner Patient List: Syncope) or regular folder– Drop cases that illustrate your progress and ability to manage SYNCOPE without supervision. Use the following list to match your cases.

A. Document cases where you were directly involved and illustrate the following a. Cases showing how you elicited a thorough and relevant medical history, perform a physical

examination and review the medical record to identify factors that led to the development of syncope.

b. Cases showing how you accurately assessed patients’ volume status and used appropriate special maneuvers to complement the physical examination to identify underlying etiologies of syncope or other causes that may mimic syncope.

c. Cases showing how you determined which patients require an evaluation of syncope as an inpatient.

d. Cases showing how you identified the most appropriate care setting and monitoring requirements for patients admitted for a syncope evaluation (with judicious but proper use of continuous telemetry, pulse oximetry, and seizure precautions).

e. Cases showing how you formulated a logical diagnostic plan to determine the cause of syncope while avoiding diagnostic tests that are rarely indicated (such as carotid ultrasonography) except in selected circumstances.

f. Cases showing how you ordered and interpreted indicated laboratory studies to evaluate for underlying conditions that may contribute to, or cause, syncope.

g. Cases showing how you appropriately ordered more advanced diagnostic studies to guide syncope evaluation, seeking guidance from specialists when necessary to interpret the results

h. Cases showing how you determined an appropriate plan to manage syncope once the etiology has been identified.

i. Cases showing how you communicated with nursing teams and implement appropriate precautions to prevent inpatient falls in patients admitted with syncope.

j. Cases showing how you communicated with patients and families to i. Explain the etiology of syncope and the importance of recognizing and preventing

recurrent syncope. ii. Explain the associated risks, required monitoring, and appropriate management of

syncope. k. Cases showing how you documented the treatment plan and provided clear discharge

instructions for post-discharge clinicians.

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Urinary Tract Infection

• Urinary tract infection (UTI) refers to a spectrum of clinical presentations ranging from asymptomatic urinary infection to acute pyelonephritis with septicemia

• UTI is a common infection diagnosed at the time of hospital admission or acquired during hospitalization

• Annually in the United States, more than 550,000 hospital discharges occur with UTI as the primary diagnosis with an average length of stay of 4 days

• UTI is the most common hospital-acquired infection, and it accounts for nearly 40% of all nosocomial infections

• Of UTIs acquired during hospitalization, approximately 75% are associated with urinary catheter use

• In addition to patients who have indwelling catheters, other populations that are at higher risk for UTIs are women and older adults, as well as those who are pregnant or have diabetes mellitus

• Symptomatic UTIs should be distinguished from asymptomatic bacteriuria, which is more common with advancing age and in persons with diabetes mellitus and should only be treated when it presents in pregnant women or men undergoing urologic procedures

• Residents diagnose, treat, and identify complications of UTI Monograph


a. Define UTI and describe the pathophysiology that leads to complicated UTI b. Describe common symptoms and signs of UTI. c. Explain the clinical spectrum of UTI, including patient populations that may present

with atypical symptoms. d. Name specific patient populations at increased risk for development of hospital-

acquired or other complicated UTIs. e. Name common community-acquired and hospital-acquired urinary pathogens. f. Explain how local and national resistance patterns affect the selection of initial

antibiotics g. Distinguish UTI from sterile pyuria and colonization. h. Explain the indications and limitations of specific tests used to diagnose UTI, its

underlying causes, and complicating conditions. i. Recognize indications for specialty consultation, which may include urology or

infectious disease services. j. Define risk factors for UTI. k. Describe the indications for appropriate urinary bladder catheterization for

hospitalized patients. l. Differentiate the specific clinical management, including antibiotic selection for

different patient populations, for patients with community-acquired UTI, hospital-acquired UTI, and incidentally recognized pyuria, as well as for patients who have chronic indwelling catheters, are pregnant, or are immunosuppressed.

m. Explain the indications for hospitalization in patients with UTI. n. Explain the goals for hospital discharge, including specific measures of clinical stability

for safe care transition.

Activity Log

Log (Suggest Creating a Cerner Patient List: UTI) or regular folder– Drop cases that illustrate your progress and ability to manage UTI without supervision. Use the following list to match your clinical cases.

A. Document cases where you were directly involved and illustrate the following

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a. Cases showing how you elicited a focused medical history to identify risk factors for and symptoms of UTI and its known complications.

b. Cases showing how you performed a targeted physical examination looking for signs of complicated UTI, sepsis, prostatitis, and other comorbid conditions.

c. Cases showing how you ordered and interpreted urinalysis and urine culture. d. Cases showing how you ordered and interpret the results of imaging studies when indicated. e. Cases showing how you formulated an initial care plan by patient risk factors, acute medical

illness, comorbid disease, and local and national antibiotic resistance patterns. f. Cases showing how you adjusted antibiotic therapy by subsequent culture results and

determined the appropriate treatment duration. g. Cases showing how you applied judicious antibiotic selection to help reduce antibiotic

resistance. h. Cases showing how you recognize and addressed complications of UTI and/or inadequate

therapeutic response. i. Cases showing how you evaluated and treated patients for UTI in the perioperative setting

when indicated. j. Cases showing how you promoted and used preventive measures, which may include early

removal and avoidance of unnecessary urinary catheters and other interventions to prevent UTI.

k. Cases showing how you communicated with patients and families to i. Explain tests and procedures and their indications and to obtain informed consent.

ii. Explain the use and potential adverse effects of pharmacologic agents. iii. Explain the goals of care, discharge instructions, and management after hospital

discharge to ensure safe follow-up and transitions of care. l. Cases showing how you documented the treatment plan and provide clear discharge

instructions for post-discharge clinicians, including duration of antibiotic treatment and the need for follow-up testing.

m. Cases showing how you provided and coordinated resources to ensure a safe transition from the hospital to arranged follow-up care.

n. Cases showing how you coordinated discharge plans when patients require ongoing skilled nursing care.

Venous Thromboembolism

• Venous thromboembolism (VTE), or clotting within the venous system, is a common and under-recognized cause of significant preventable morbidity and mortality in hospitalized patients

• VTE includes deep vein thrombosis (DVT) and pulmonary embolism (PE). Each year, 300,000 to 600,000 Americans are affected by VTE

• VTE is a serious condition that carries a substantial risk of mortality and long-term complications such as chronic venous insufficiency, major bleeding during anticoagulation therapy, and recurrent disease

• Annually, VTE may be responsible for more than 100,000 deaths in the United States, and it is the most common preventable cause of hospital death

• Residents should participate with their institutions in the development of screening and prevention protocols for patients at risk for VTE and the promotion of early diagnosis and safe treatment approaches

Monograph


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a. Describe VTE pathophysiology, including contributing aspects of endothelial damage, stasis, and alteration of the coagulation cascade.

b. Describe the epidemiology of VTE, including the effects of demographic, environmental, thrombophilic, and hormonal factors, underlying medical and surgical conditions, and length of stay.

c. Explain the clinical presentation of VTE and describe the algorithmic diagnostic approach.

d. Describe the indications, accuracy, and limitations of specific diagnostic tests. e. Explain when invasive testing, including pulmonary angiography and venography, is

indicated and list the contraindications and potential complications of such testing. f. Recognize indications and poor prognostic factors that necessitate early specialty

consultation, which may include interventional radiology, vascular surgery, and hematology.

g. Describe VTE prophylaxis regimens for specific hospitalized risk groups including medical, general surgical, orthopedic, neurosurgical, obstetric, and critically ill patients.

h. Explain the indications for hospitalization and admission to the intensive care unit. i. Explain the indications, contraindications, and adverse effects of thrombolytic therapy

in the setting of VTE. j. Explain indications, contraindications, and mechanisms of action, and reversal agents

for pharmacologic drugs used to treat VTE. k. Explain the role and potential adverse effects of other therapeutic modalities in the

setting of VTE, including different anticoagulation regimens, vena cava interruption, thrombolysis, and embolectomy.

l. Describe the risk of adverse outcomes from VTE. m. Describe the risks and potential harm associated with pressure gradient stockings. n. Recognize when to prescribe post-discharge prophylaxis. o. Explain goals for hospital discharge including specific measures of clinical stability for

safe care transitions.

Activity Log

Log (Suggest Creating a Cerner Patient List: VTE) or regular folder– Drop cases that illustrate your progress and ability to manage VTE without supervision. Use the following list to match your cases.

A. Document cases where you were directly involved and illustrate the following a. Cases showing how you elicited a thorough and relevant medical history and reviewed the

medical record to identify relevant risk factors and symptoms consistent with VTE. b. Cases showing how you performed a complete physica l examinat io n to identify clinical

features that predict the presence of VTE and significant clot burden, including evidence of pulmonary hypertension, right heart failure, low perfusion state, and underlying malignancy.

c. Cases showing how you analyzed history and physical findings to determine pretest probability for DVT and/or PE.

d. Cases showing how you integrated evidence-based diagnostic testing to establish the diagnosis or exclusion of VTE or need for additional testing strategies.

e. Cases showing how you assessed the need for urgent invasive treatment modalities including thrombolysis or embolectomy.

f. Cases showing how you determined the appropriate level of inpatient care required. g. Cases showing how you formulated a treatment plan tailored to the individual patient

including a selection of a specific anticoagulation regimen or suitable alternative therapy. h. Cases showing how you anticipated and address factors that may complicate VTE or its

management including cardiopulmonary compromise, bleeding, and/or anticoagulation failure i. Cases showing how you addressed and managed pain, dyspnea, and swelling in patients with

VTE. j. Cases showing how you performed VTE risk assessment in all hospitalized patients and

initiated indicated prophylactic measures, including pharmacologic agents, mechanical devices, and/or ambulation to reduce the likelihood of VTE.

k. Cases showing how you facilitated comanagement of VTE treatment and prevention when requested by other services.

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l. Cases showing how you educated clinicians and nurses in VTE risk assessment and preventive measures.

m. Cases showing how you communicate with patients and families to i. Explain the natural history and prognosis of VTE.

ii. Explain tests and procedures and their indications and to obtain informed consent. iii. Explain the use and potential adverse effects of pharmacologic agents. iv. Explain the goals of care, discharge instructions, and management after hospital

discharge to ensure safe follow-up and transitions of care. n. Cases showing how you prescribed treatments to decrease the risk of post-thrombotic syndrome

upon hospital discharge. o. Cases showing how you ensured adequate resources, including monitoring of anticoagulation,

for patients between hospital discharge and arranged outpatient follow-up. p. Cases showing how you documented the treatment plan and provide clear discharge

instructions for post-discharge clinicians responsible for monitoring anticoagulation.

Health Care Systems Dynamics

Drug Safety, Pharmaco-economics, and Pharma-epidemiology

• Pharmacotherapy is a key part of the work of a physician.

• Physicians in almost any specialty must understand how to evaluate the benefits, harms, and financial costs of drug therapy for individual patients.

• Pharmaceutical costs have grown more than any other sector of healthcare, as have concerns about

adverse drug events.

• Hospitalists often participate in the development and implementation of protocols and clinical

pathways that recommend preferred drug therapies within their institutions.

• To participate effectively in these decisions, they must be able to interpret outcomes measurement

(pharmacoepidemiology) and economic analyses (pharmacoeconomics).

Monograph


a. Evaluation of parameters that can affect the choice of pharmacotherapy including but not limited to:

i. Clinical efficacy ii. Adverse effects

iii. Kinetics iv. Costs

b. Rationale for prophylactic drug therapies c. Principles of antimicrobial stewardship d. Interpretation of pharmaeconomic analyses e. Effects of age on pharmakinetics and pharmacodynamics f. Effects of ICU on pharmakinetics and pharmacodynamics g. Deprescribing initiatives h. Optimization of pharmacotherapy during hospitalization.

Activity Log

Log (Suggest Creating a Cerner Patient List: Pharmacotherapy and a system to track other activities) or regular folder– Drop cases that illustrate your progress and ability to manage this topic without supervision. Use the following list to match your cases.

a. Cases showing your ability to individually tailor pharmacotherapy based on comorbid conditions or altered kinetics

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b. Cases showing that you apply antimicrobial treatment guidelines to reduce cost and slow the emergence of resistance

c. Cases showing that you use best practices with regard to medication ordering and administration to reduce adverse drug events

d. Cases that you arranged adequate follow-up for therapies that require outpatient monitoring. e. Cases showing your involvement in medication reconciliation, admission, transfer, and

transition to community f. Cases showing following patients as outpatient after hospitalization with medication

reconciliation and education. Other:

a. Participate in the P&T committee or Antimicrobial Stewardship Program.

a. Provide proof of attendance to these meetings.

Equitable Allocation of Resources

• The United States spends more than any other country on healthcare, with expenditures totaling $3.2 trillion in 2015 ($9900 per capita or 17.8% percent of gross domestic product) in 2015.

• Hospital care has consistently accounted for the largest portion.

• As providers of cost-conscious care, hospitalists are involved in the coordination and allocation of

healthcare resources.

• Differences in race, ethnicity, and socioeconomic status make patients vulnerable to health care inequalities.

• Hospitalists are positioned to identify such disparities and advocate for equitable allocation of resources to optimize care for all patients.

Monograph


a. Concepts of equity and cost-effectiveness b. How to use decision analysis, cost-effectiveness analysis, and cost-benefit analysis; c. Identify health resources and patient populations that are at risk for inequitable

allocations d. Recognize that equity in health care is cost effective yet these concepts may conflict in

health care policies. c. Activity Log

d. Log (Suggest Creating a Cerner Patient List: Allocation Resources and a system to track other activities) or regular folder– Drop cases that illustrate your progress and ability to manage this topic without supervision. Use the following list to match your cases.

a. Cases showing your ability to monitor for equity in health care among hospitalized patients through measurement of patient access to hospital resources, and practice evidence-based, high-value care for all patients.

b. Cases demonstrating that you advocated for i. Every patient’s needed health care services

ii. Act on cultural differences or language barriers that may inhibit health care quality

iii. Coordinated or participated in multidisciplinary teams to track utilization and outcomes; decrease costs; and provide evidence-based, cost-effective care with equitable access.

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Leadership

• As family medicine residents gain knowledge and skills throughout their training, they are called upon

to effectively lead both in the outpatient and inpatient settings.

• Family physicians are trained to think critically and act creatively during difficult situations and in

times of crisis.

• Hospitalists trained in family medicine must acquire and demonstrate competency in these effective leadership skills, which will also equip them to attain other leadership roles, specifically, within the

hospital setting.

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a. How to be an effective leader, including, how to foster the development of mentor/mentee relationships and continue to develop these relationships in their future practice of hospital medicine and recognize the differences between management and leadership.

Activity Log

Log regular folder– Document instances that illustrate your progress and ability to manage this topic without supervision. Use the following list to document.

a. Meetings with Junior residents for mentoring purposes b. Presentations during professional development related to hospital medicine c. Facilitating the Inpatient Clinical Huddle d. Participation in multidisciplinary meetings or committees e. Participation in the design, implementation, or collection of performance metrics.

Management Practices

• Traditionally, as ambulatory care-based family physicians are responsible for demonstrating

competency in ambulatory practice management, hospitalists trained in family medicine are also

responsible for competency in hospital based practice management.

• Family medicine residents should demonstrate competency in inpatient practice management to allow

them to define their future role and value as a hospitalist.

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a. Providing cost-conscious inpatient medical care b. Existence of different models of hospital physician compensation and incentives c. Potential impacts of healthcare reform and other policies d. Basic billing and coding requirements. e. Patient E/M documentation and levels of billing f. DRG concepts g. RVU h. Bundles i. Core measures

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Activity Log

a. Log (Suggest Creating a Cerner Patient List: Management and a system to track other activities) or regular folder– Drop cases that illustrate your progress and ability to manage this topic without supervision. Use the following list to match your cases.

a. Cases showing that you provided cost-conscious inpatient medical care b. Cases demonstrating that you are competent in

i. inpatient billing ii. utilization of current procedural terminology (CPT) codes and relative value

units (RVUs) iii. utilization of average length of stay, and case mix index.

Medical Consultation and Co-management

• Hospitalists may provide expert medical opinion regarding the care of hospitalized patients or may serve as consultants for patients under the care of other medical and surgical services.

• The hospitalist consultant may provide opinions and recommendations or actively manage the patient’s hospital care.

• Effective and frequent communication between the hospitalist and the requesting physician ensures

safe and quality care.

• Hospitalists should promote communication between services to improve the care of the hospitalized

patient, optimize resource utilization, and enhance patient safety.

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a. Define the role of the hospitalist consultant and describe the components of an effective consultation.

Activity Log

Log (Suggest Creating a Cerner Patient List: Consultation and a system to track other activities) or regular folder– Drop cases that illustrate your progress and ability to manage this topic without supervision. Use the following list to match your cases.

a. Cases showing your ability to synthesize, document, and communicate concise but specific recommendations to the person requesting consultation based on a thorough gathering of subjective and objective data.

Nutrition and the Hospitalized Patient

• Optimal nutrition in the hospital can facilitate better patient outcomes.

• Malnutrition in hospitalized patients can lead to poor wound healing, impaired immune function resulting in infectious complications, increased hospital length of stay, increased risk of readmission, and overall increased morbidity and mortality

• Malnutrition is reported in up to 50% of hospitalized patients

• Although early screening for nutritional risk allows for appropriate intervention in the hospital setting as well as planning for proper home services and follow-up for outpatient dietary care, malnutrition is under-recognized and undertreated

• In malnourished patients, nutritional intervention has been shown to reduce clinical complications, length of stay, readmission rates, and mortality

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• Residents use a multidisciplinary approach to evaluate and address the nutritional needs of hospitalized patients

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a. Describe methods of screening for malnutrition. b. Describe the consequences of malnutrition on bodily function, illness, and outcomes. c. Explain when a nutrition evaluation by a registered dietitian is required. d. Differentiate among various modified diets and nutritional supplements and explain the

indications for each. e. Explain the indications and contraindications for enteral nutrition. f. Describe the indications for parenteral nutrition. g. Describe potential complications associated with enteral and parenteral nutrition. h. Recognize that specialized nutritional supplementation may be required in specific

patient populations, which include patients with extensive wounds or increased catabolic needs.

i. Explain the risk factors for and the clinical features of the refeeding syndrome.

Activity Log

Log (Suggest Creating a Cerner Patient List: Nutrition) or regular folder– Drop cases that illustrate your progress and ability to manage NUTRITION without supervision. Use the following list to match your cases.

A. Document cases where you were directly involved and illustrate the following a. Cases showing how you used objective criteria, including history, physical examination findings,

and laboratory results, to diagnose and categorize the severity of malnutrition and identify patients who are at increased risk.

b. Cases showing how you identified the symptoms or signs of medical conditions that are associated with or secondary to malnutrition and formulated an evidence-based treatment plan.

c. Cases showing how you implemented individualized modified diets and/or nutritional supplements, which may include total parenteral nutrition, by the patient’s medical condition.

d. Cases showing how you treated electrolyte abnormalities associated with the refeeding syndrome.

e. Cases showing how you monitored electrolytes as indicated in the setting of enteral and/or parenteral nutritional support.

f. Cases showing how you consulted a nutrition specialist for a comprehensive nutritional evaluation when indicated.

g. Cases showing how you coordinated follow-up nutrition care as part of discharge plans for those patients requiring nutritional support.

h. Cases showing how you lead, coordinated, and/or participated in initiatives to improve awareness and documentation efforts that appropriately categorize the patient with malnutrition and determine the impact this may have on risk-adjusted mortality and value-based purchasing.

i. Cases showing how you lead, coordinated, and/or participated in multidisciplinary initiatives to optimize resource use.

j. Cases showing how you lead, coordinated, and/or participated in the development of care pathways for patients requiring enteral or parenteral nutrition

k. Cases showing how you drive, organized, and/or engaged in efforts to develop strategies to minimize institution complication rates

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Palliative Care

• Palliative care refers to the comprehensive care of patients and families who are living with serious illness

• It focuses on providing patients with relief from the symptoms and stress of serious illness

• The goal is to improve the quality of life for both the patient and the family

• Palliative care is appropriate at any stage of disease and should be provided simultaneously with other medical treatments, including disease-modifying and life-prolonging therapies

• Palliative care is provided by inter-professional teams, including physicians, nurse practitioners, physician assistants, nurses, social workers, case managers, and chaplains.

• Seriously ill patients are frequently hospitalized, and thus all Residents who coordinate care for these patients—are key members of the inter-professional team who provide primary or generalist palliative care.

• Also, in hospitals where palliative care consultation services are available, Residents are optimally positioned to refer to and collaborate with these specialty palliative care consultants

• In hospitals where no or limited specialty palliative care services are available, Residents have an even more central role in providing palliative care.

• Key roles for Residents involved in palliative care are leading discussions of goals of care and advance care planning, including

o Completing appropriate documentation of patients’ wishes

o Screening and implementing treatment for common physical symptoms, including pain, nausea and vomiting, dyspnea, anxiety, depression, confusion and delirium, and constipation

o Referring patients to community services to provide support around serious illness after hospital discharge, including hospice and community palliative care services when available.

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a. Define palliative care, including primary (or generalist) and specialty palliative care, and teach practical strategies for representing the benefits of palliative care to colleagues, specialists, patients, and families.

b. Explain the role of palliative care throughout the illness, how it can be provided alongside all other appropriate medical treatments, and proper referral to local resources that provide palliative care in the hospital and community.

c. Recognize when specialty palliative care consultation, when it is available, should be sought for refractory or complex patient or family palliative care needs.

d. Identify the factors that contribute to prognosis in common serious illnesses (e.g., cancer, congestive heart failure, chronic obstructive pulmonary disease, end-stage renal disease, dementia, and multi-morbidity)

Log (Suggest Creating a Cerner Patient List: Palliative Care) or regular folder– Drop cases that illustrate your progress and ability to manage PALLIATIVE CARE without supervision. Use the following list to match your cases.

A. Document cases where you were directly involved and illustrate the following a. Cases showing how you performed a comprehensive patient assessment to screen patients for

palliative care needs, including (1) pain and other common symptoms (e.g., nausea and vomiting, dyspnea, anxiety,

depression, confusion and delirium, constipation) (2) psychosocial and spiritual support of the patient and family (3) advance care planning communication about prognosis and goals of care; and (4) needs for support on hospital discharge or bereavement.

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b. Cases showing how you worked in interdisciplinary teams, including nursing, social work, case management, therapy, and spiritual care, to formulate specific patient-centered palliative care plans to address identified patient and family needs.

c. Cases showing how you built therapeutic relationships with seriously ill patients and their families as a basis of support for coping and creating collaborative patient- and family-centered care plans

d. Cases showing how in severely ill and/or actively dying patients, provided first-line treatment for common symptoms such as nausea and vomiting, dyspnea, anxiety, depression, confusion and delirium, and constipation.

e. Cases showing how you provided counseling on advance care planning, advance care directives, POLST/MOLST forms, and code status, including the outcomes of cardiopulmonary resuscitation and other life-sustaining interventions in severely ill patients.

f. Cases showing how you lead culturally sensitive communications about prognosis and goals of care among patients, families, and other members of the healthcare team, including family meetings and discussions in urgent situations to ensure that patients receive treatments that match their goals.

g. Cases showing how you coordinated goals of care and treatment plan among the treatment team, including primary care physicians and inpatient and outpatient specialty consultants.

h. Cases showing how you consulted specialty palliative care and/or hospital ethics service when there is conflict among patients, families, and/ or healthcare providers regarding the appropriate healthcare agent for decision-making and provision of life-sustaining interventions.

i. Cases showing how you identified when hospice might be the appropriate care model given a patient’s prognosis and goals of care and describe the hospice care philosophy and care model to a patient and family.

j. Cases showing how you implemented protocols and multidisciplinary care plans to ensure patient comfort and adequate family support when life-prolonging measures such as mechanical ventilation, vasopressor support, or other intensive care measures are withdrawn or withheld.

Patient Handoff

• Patient handoff is the interaction, communication, and planning required to seamlessly transition care from one provider to another.

• Hospitalists transfer care of patients on a daily basis and having an effective handoff is extremely important.

o This avoids medical errors and adverse events and provides high-quality medical care.

• Two important components are for the hand off to be effective and timely.

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a. Models for handoff with validation studies b. Describe key elements of high-quality patient handoffs. c. Describe barriers to effective handoffs and ways to avoid them. d. Utilization of electronic health record features to optimize handoff

Activity Log

a. Log (Suggest Creating a Cerner Patient List: Handoff and a system to track other activities) or regular folder– Drop cases that illustrate your progress and ability to manage this topic without supervision. Use the following list to match your cases.

a. Cases showing that you are able to i. communicate effectively and efficiently using read-back techniques

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ii. create patient summaries iii. evaluate medications and critical tasks

b. Cases that illustrates how handoff decrease patient risk for harm c. Activity logs of forms used for handoff d. Involvement in any committee to develop, implement, or QI handoff programs.

Patient Safety

• The National Patient Safety Foundation defines safety as the avoidance, prevention, and amelioration of adverse outcomes or injuries stemming from the processes of healthcare.

• Hospitalized patients are at risk for a variety of adverse events

• Residents should anticipate complications from medical assessment and treatment and take steps to reduce their incidence or severity

• Application of individual and system failure analysis can improve patient safety

• Residents should participate in multidisciplinary interventions to mitigate system and process failures and to assess the effects of recommended interventions across the continuum of care.


a. Define and differentiate medical errors, adverse events, and preventable adverse events. b. Identify the most common safety problems and their causes in different hospitalized

patient populations. c. Explain the role of human factors in the device, procedure, and technology-related

errors. d. Explain how redundant systems may reduce the likelihood of medical errors. e. Specify clinical practices and interventions that improve the safe use of high-alert

medications. f. Summarize methods of system and process evaluation of patient safety. g. Describe the elements of well-functioning patient safety-focused teams. h. Distinguish retrospective and prospective methods of evaluating medical errors. i. Describe the components of Root Cause Analysis (RCA) and Failure Mode and Effects

Analysis (FMEA). j. Describe principles of medical error disclosure. k. Discuss the significance of sentinel events and “near misses” and their relationship to

voluntary and mandatory reporting regulations. l. Describe the risk management issues of patient safety efforts. m. Judge the effect of patient volume on the quality, efficiency, and safety of healthcare

services.

Log (Suggest Creating a Cerner Patient List: Safety) or regular folder– Drop cases that illustrate your progress and ability to manage SAFETY without supervision. Use the following list to match your cases.

A. Document cases where you were directly involved and illustrate the following a. Cases showing how you prevented iatrogenic complications and proactively reduced risks of

hospitalization. b. Cases showing how you formulated age- and disease-specific safety practices, which may

include but are not limited to reduction of incidence and severity of falls, decubitus ulcers, delirium, hospital-acquired infections, venous thromboembolism, malnutrition, and medication adverse events.

c. Cases showing how you developed, implemented and evaluated practice guidelines and care pathways as part of an interdisciplinary quality improvement initiative.

d. Cases showing how you gathered, recorded and transferred patient information by adhering to timely, accurate, and confidential mechanisms.

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e. Cases showing how you prioritized patient safety evaluation and improvement efforts by the impact, improvability, and general applicability of the proposed evaluations and interventions.

f. Cases showing how you developed systems that promote patient safety and reduce the likelihood of adverse events.

g. Cases showing how you contributed to and interpreted retrospective RCA and prospective healthcare FMEA multidisciplinary risk evaluations.

h. Cases showing how you appropriately engaged in standardized communication practices such as Situation-Background-Assessment-Recommendation (SBAR).

i. Cases showing how you facilitated practices that reduce the likelihood of hospital-acquired infection.

j. Cases showing how you used evaluation methods and resources to define problems and recommend interventions.

k. Cases showing how you employed continuous quality improvement techniques to identify, construct, implement, and evaluate patient safety issues.

l. Cases showing how you lead, coordinated, and/or participated in multidisciplinary teams to improve the delivery of safe patient care.

m. Cases showing how you lead, coordinated, and/or participated in the development, use, and dissemination of local, regional, or national clinical practice guidelines and patient safety alerts about the prevention of complications in hospitalized patients.

n. Cases showing how you lead, coordinated, and/or participated in efforts to advance the culture of patient safety in the hospital.

Prevention of Healthcare-associated Infections and Antimicrobial Resistance

• Just as Family Physicians in an ambulatory environment are responsible for antibiotic stewardship, family medicine trained hospitalists are tasked with the prevention of nosocomial infections in the

hospital setting.

• Nosocomial infections often lead to increases in length of hospitalization and result in excess costs

annually.

• Hospital physicians should work in concert with other members of the healthcare organization to reduce healthcare-associated infections, develop institutional initiatives for prevention, and promote

and implement evidence-based infection control measures.

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a. Guidelines for healthcare associated infections b. isolation precautions approach and definitions c. Specific indications for isolation precautions d. Criteria to discontinue isolation precautions e. Role of antibiogram in hospital setting. f. Use of inflammatory biomarkers (example procalcitonin) in initiation, monitoring, de-

escalation, or discontinuation of antibiotics.

Activity Log

Log (Suggest Creating a Cerner Patient List: Prevention Healthcare Associated Infections and a system to track other activities) or regular folder– Drop cases that illustrate your progress and ability to manage this topic without supervision. Use the following list to match your cases.

a. Cases showing utilization of infection control and prevention technique

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b. Cases showing appropriate ordering for isolation precautions, follow up and discontinuation. c. Cases showing utilization of antibiogram for empiric initiation of therapy and follow up with

optimization of treatment based on biomarkers or in-vitro antibiogram. d. Meetings or rotation documentation with infection control.

Quality Improvement

• Hospitalists practice within the healthcare delivery system and processes of their organizations and institutions.

• As such, participation in the quality improvement (QI) of these systems is an essential competency of the hospitalist.

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a. Guidelines and protocols that have been developed based on outcome measures, as well as required institutional reporting of these outcome measures and recognition of institutional variation in care delivered and the potential contributing factors for these quality gaps.

b. Describe the role of organizational culture and reliability, multidisciplinary teamwork, and use of tools and protocols to ensure highest quality performance.

Activity Log

Log (Suggest Creating a Cerner Patient List: QI and a system to track other activities) or regular folder– Drop cases that illustrate your progress and ability to manage this topic without supervision. Use the following list to match your cases.

a. Cases or projects showing your ability to collect and apply data using evidenced based tools to continuous multidisciplinary QI efforts aimed at reducing care variation, enhancing patient safety and satisfaction, and addressing inefficiencies and inequities.

b. Participation in any evidence based strategies and initiatives c. Demonstrate attendance to QI hospital committee.

Team Approach to Multidisciplinary Care

• Multidisciplinary care refers to active collaboration between various members in the healthcare system to develop optimal care plans for each patient.

• The hospital environment is well suited for team-based, multidisciplinary care since team members work in the same physical space and patients are present to participate in decisions about their care.

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a. Describe the major elements of teamwork b. List major barriers to effective team interactions c. Describe aspects within an institution which can impact the structure and function of

multidisciplinary teams.

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Activity Log

Log (Suggest Creating a Cerner Patient List: Team-Multidisciplinary and a system to track other activities) or regular folder– Drop cases that illustrate your progress and ability to manage this topic without supervision. Use the following list to match your cases.

a. Cases, meetings or activities demonstrating: a. Ability to determine an effective team composition b. Demonstrate group dynamic skills c. Integrate the assessments and recommendations of all contributing team members into the

care plan and to conduct efficient and effective multidisciplinary team rounds.

Transitions of Care

• Transitions of care refers to any transfer of patient location, service or provider including admission to the hospital, transfer to another hospital or service, elevation of care to the ICU, discharge to home, a

rehabilitation center or nursing center and the communication and dialogue necessary to ensure that

these transitions are done safely and effectively.

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a. Define relevant information that should be retrieved and communicated during each care transition to ensure patient safety and maintain the continuum of care.

b. Describe the value of available ancillary services that can facilitate patient transitions. c. Identify and utilize the most efficient, reliable and expeditious communication

modalities for each care transition and ensure that communication is succinct and to develop a care plan early that includes information received from referring physicians.

d. Validated guidelines for safe transition e. Validated interventions to identify risk for readmissions. f. Identified tools to decrease chances of readmissions.

Activity Log

Log (Suggest Creating a Cerner Patient List: Transition and a system to track other activities) or regular folder– Drop cases that illustrate your progress and ability to manage this topic without supervision. Use the following list to match your cases.

a. Cases showing the transition process, that illustrates the importance of a multidisciplinary approach for patient and families.

b. Cases seen

● Expected resident attitudes include the appreciation of the impact of care transitions on patient

outcomes and satisfaction, recognition of the importance of a multidisciplinary approach to transitions

of care, preparation of the patient and family for care transitions, and utilization of real time dialogue

with other clinicians.

Initiatives/Educational Prescriptions/Critical Appraised Topics: Use a narrative form

to describe if any participation or activity. a. Initiatives – Document and submit if:

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i. Have you lead, coordinate or participate in efforts to develop protocols to identify patients with rapidly

1. DDM and minimize time to intervention 2. Facilitate early identification of AKI and improved patient outcomes 3. Efficient and timely evaluation and treatment of patients with alcohol and drug

withdrawal ii. Have you lead, coordinate or participate in efforts between institutions to develop

evidence-based protocols for 1. Rapid identification and transfer of patients with DDM to appropriate facilities. 2. Promotion of patient safety and optimizing management strategies for AKI 3. Treatment of withdrawal syndromes 4. Optimize cost-effective diagnostic and management strategies for patients with

asthma 5. Optimize cost-effective diagnostic and management strategies for patients with

COPD. 6. Early identification of arrhythmias, reduce preventable complications and

promote appropriateness use of telemetry resources 7. Evidence-based clinical severity scores and clinical judgment into admission

decisions for CAP 8. Early treatment protocols for Delirium 9. Assessment and management of uncontrolled diabetes, DKA, and HSS. 10. Management of GI bleeds 11. Reduced incidence of HAP and variance in antibiotic use 12. Management strategies for hyponatremia 13. Measuring quality of inpatient pain control, operationalize system

improvements, and reduce barriers to adequate pain control 14. Efforts to improve the efficiency and quality of care through innovative models,

which may include co-management of surgical patients in the perioperative process

15. Developing protocols for the rapid identification and transfer of patients with sepsis to appropriate facilities.

16. Management strategies for syncope 17. Participate, lead, or coordinate in efforts to apply high-value care to the

evaluation of a patient with uncomplicated syncope (e.g., avoidance of neuroimaging and the carotid US)

18. Minimize use and duration of urinary catheters and to reduce the incidence of hospital-acquired UTI

19. Implementation of screening and prevention protocols for hospitalized patients by national evidence-based recommendations for DVT prophylaxis

iii. Have you implemented systems to ensure hospital-wide adherence to national standards, and document those measures as specified by recognized organizations (JCAHO, AHA/ACC, AHRQ or others).

iv. Have you lead, coordinate or participate in multidisciplinary initiatives to promote patient safety and optimize resource utilization, which may include

1. DDM and chest pain order sets. 2. Reducing the incidence of iatrogenic AKI 3. Management strategies for patients with substance abuse 4. Educational modules, order sets, and/or pathways that facilitate the use of

evidence-based strategies for a. Asthma exacerbations with goals of improving outcomes, decreasing

length of stay and reducing rehospitalization

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b. COPD exacerbation in the emergency department and the hospital with the goal of improving outcomes, decreasing length of stay and reducing re-hospitalizations.

5. Cost effective diagnostic and management strategies for patients with CAP 6. Implementation of screening and prevention protocols for patients at risk for

delirium 7. Management strategies for patients with delirium and dementia 8. Diabetes management and glycemic control in hospitalized patients

including suitable regimens in critically medical and surgical patients 9. Promotion of early identification of GI bleeds and reduces preventable

complications. 10. Improve patient function and outcomes in patients with heart failure 11. Reducing the spread of resistant organisms within the institution 12. Pathways to improve the timing and quality of perioperative care from initial

perioperative through care transitions 13. Promotion of guidelines and/or pathways that facilitate efficient and timely

evaluation and treatment of patients with sepsis 14. Cost effective diagnostic and management strategies for patients with

cellulitis 15. Develop protocols to rapidly identify patients with stroke who have

indications for acute interventions and to minimize time to response. 16. Develop or implement protocols to promote patient safety and optimize

resource use, including aggressive treatment of risk factors and rehabilitation for patients with stroke.

17. Improve patient care efficiency, facilitate early discharge, and encourage the outpatient management of VTE

v. Instances where you have lead efforts to educate staff on the importance of smoking cessation counseling and other prevention measures.

vi. Have you integrated outcomes research, institution-specific laboratory policies, and hospital formulary to create indicated and cost-effective diagnostic and management strategies for patients with AC

vii. Have you coordinated initiatives to address the increased risk of readmissions associated with:

1. Substance abuse and polysubstance abuse 2. Asthma 3. COPD 4. Stroke 5. Heart failure

viii. Have you established relationships with and develop knowledge of community-based organizations that provide support to:

1. Patients with substance abuse disorders ix. Have you been an advocate for hospital resources to improve the care of patients with

1. Substance withdrawal and the environment in which the care is delivered 2. Elderly patients

x. Have you been involved in integrating outcomes research, institution-specific laboratory policies, and hospital formulary to create indicated and cost-effective and diagnostic and management strategies for any of the core topics.

xi. Have you participated in any multidisciplinary team to develop patient care guidelines and/or pathways by peer-reviewed outcomes research, patient and physician satisfaction, and cost.

b. Educational Prescriptions: i. Collect educational prescriptions that you have prepared related to DDM.

c. Critical Appraised Topics

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i. Collect CATs that you have worked related to DDM. d. Other – Collect cases related to:

i. ECGs ii. Imaging

iii. Laboratory

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