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Core Competencies in Hospital Medicine 2017 Revision. Section 2: Procedures

© 2017 Society of Hospital Medicine

Core Competencies Table of Contents

SECTION 2: PROCEDURES

2.1 ARTHROCENTESIS

Arthrocentesis, the aspiration of synovial fluid from a joint, is frequently performed in the diagnosis and management of joint effusions to determine whether these are associated with infectious, traumatic, or rheumatologic conditions. More than 38,000 arthrocentesis procedures are performed annually in US hospitals.1 Hospitalists may identify a joint effusion during the history and physical examination and should use clinical expertise and evidence-based decision-making to determine whether arthrocentesis is required in the diagnosis and management of the patient’s illness.

KNOWLEDGE
Hospitalists should be able to:

  • Define and differentiate the disease processes that may lead to the development of joint effusion.
  • Distinguish between the clinical features of a joint effusion and soft tissue swelling surrounding a joint. 
  • Explain indications and contraindications for arthrocentesis including potential risks, benefits, and complications.
  • Identify and locate anatomic landmarks to guide proper entry points for arthrocentesis.
  • Describe indications for the use of ultrasonography to assess and/or to guide arthrocentesis.
  • Explain the appropriate diagnostic tests to accurately characterize synovial fluid.
  • Recognize the indications to pursue additional radiographic imaging to further characterize a joint effusion.
  • Recognize the indications for specialty consultations, which may include orthopedic surgery, rheumatology, infectious diseases, or interventional radiology.

SKILLS
Hospitalists should be able to:

  • Elicit a thorough and relevant medical history to identify comorbid conditions and risk factors for the development or complications of a joint effusion.
  • Perform a physical examination to evaluate for signs to determine the primary condition responsible for the development of a joint effusion, including traumatic injury, infection, inflammation, or rheumatologic disease.  
  • Demonstrate the optimal position for the patient and the patient’s joint to perform an arthrocentesis.
  • Select the necessary equipment to safely perform arthrocentesis.
  • Perform a time-out before the procedure.
  • Use appropriate sterile technique throughout the procedure to minimize risk of infectious complications for patients and providers. 
  • Anticipate and manage complications of arthrocentesis after the procedure, which may include bleeding, hematoma, or infection.
  • Interpret cell counts and biochemical analysis of synovial fluid to determine an appropriate management plan. 
  • Appropriately use splinting and analgesia to reduce joint inflammation and pain when indicated. 
  • Employ multidisciplinary teams, including physical and occupational therapy, to assist with inpatient and outpatient rehabilitation when appropriate.
  • Obtain informed consent and effectively communicate with patients and families to explain the procedure, its expected diagnostic or therapeutic benefits, and potential complications. 

ATTITUDES
Hospitalists should be able to:

  • Demonstrate awareness of and ability to address periprocedural emotional and physical discomfort.

SYSTEM ORGANIZATION AND IMPROVEMENT
To improve efficiency and quality within their organizations, hospitalists should:

  • Lead, coordinate, and/or participate in multidisciplinary initiatives to optimize resource use.
  • Lead, coordinate, and/or participate in efforts to develop strategies to minimize institutional complication rates of arthrocentesis.
  • Lead, coordinate, and/or participate in patient safety and quality improvement programs to monitor hospitalists’ performance and/or supervision of procedural competence.
  • Lead, coordinate, and/or participate in patient safety programs designed to coordinate care transition and the handoff of pending test results at the time of hospital 
  • discharge.

References
1.     Agency for Healthcare Research and Quality. Healthcare Cost and Utilization Project. U.S. Department of Health & Human Services. Available at: http://hcupnet.ahrq.gov/. Accessed May 2015.

2.2 CHEST RADIOGRAPH INTERPRETATION

Chest radiograph (or chest x-ray; CXR) uses low-level radiation to form an image of the chest anatomy. It is a noninvasive and readily available radiologic study that is an integral part of the initial evaluation of patients with known or suspected cardiopulmonary pathology. It is also a valuable tool to monitor treatment response or to determine interval change for a variety of cardiopulmonary disorders. The CXR is the most common diagnostic x-ray examination, and more than 20 million CXRs are performed annually in US emergency departments.1,2 Hospitalists interpret the results of CXRs, often before radiologists, to diagnose, assess disease severity, and develop treatment plans in hospitalized patients.

KNOWLEDGE
Hospitalists should be able to:

  • Explain the normal anatomy of the thorax with particular attention to spatial relationships.
  • Describe the patterns seen on CXR, including those of bone and soft tissue structures, airway, lungs, cardiac structure and silhouette, aorta, and diaphragm.
  • Explain the indications, limitations, alternatives, and potential adverse effects of CXR.
  • Compare the indications and limitations of a portable CXR study with those of a standard study.
  • Explain the indications for ordering CXR with special views or patient position.
  • Describe the effects of film exposure, inspiratory effort, and patient position on the CXR image.
  • Explain the effects of various abnormal processes on the CXR image.
  • Explain the limitations of various CXR findings.

SKILLS
Hospitalists should be able to:

  • Identify normal variants on CXR.
  • Identify abnormalities on CXR and, when possible, correlate the results with the patient’s clinical presentation and findings.  
  • Synthesize CXR findings with other clinical and diagnostic information to diagnose disease and develop a clinical plan.
  • Communicate with patients and families to explain results of CXRs and how the findings influence the care plan. 

ATTITUDES
Hospitalists should be able to:

  • Prioritize prompt interpretation of CXRs.
  • Recognize the value of comparing the current CXR with historical CXR images, when available. 
  • Adopt a standardized and consistent approach to interpreting CXR images.
  • Consult and work collaboratively with radiologists in interpreting complex CXRs and in ordering further diagnostic studies or procedures on the basis of CXR interpretation.  

SYSTEM ORGANIZATION AND IMPROVEMENT
To improve quality and efficiency within their organizations, hospitalists should:

  • Lead, coordinate, and/or participate in multidisciplinary initiatives to optimize resource use. 
  • Lead, coordinate, and/or participate in efforts directed towards system improvements related to the acquisition and interpretation of CXR for hospitalized patients.
  • Lead, coordinate, and/or participate in patient safety programs designed to coordinate care transition and the handoff of pending study results at the time of hospital discharge.

References
1.     McCaig LF, Burt CW. National Hospital Ambulatory Medical Care Survey: 2002 emergency department summary. Adv Data. 2004;340:1-34.
2.     National Heart, Lung, and Blood Institute. What Is a Chest X-Ray? Available at: www.nhlbi.nih.gov/health/health-topics/topics/cxray. Accessed May 2015.

2.3 ELECTROCARDIOGRAM INTERPRETATION AND TELEMETRY MONITORING

Heart disease continues to be the leading cause of hospital admissions and mortality in the United States. The electrocardiogram (EKG), a graphical representation of cardiac electrical potentials, is a noninvasive, readily available diagnostic tool. It remains the most commonly used investigative modality for the initial evaluation of cardiovascular disease. EKG is also the cornerstone for assessing acute coronary syndrome and various cardiac arrhythmias, and the results may critically alter a patient’s diagnosis, treatment, and prognosis. Hospitalists interpret EKG tracings expediently and apply the results to estimate risk, diagnose disease, and determine therapeutic needs of hospitalized patients. Continuous cardiac monitoring (telemetry) is another valuable diagnostic modality that is frequently used in the evaluation of hospitalized patients. 

KNOWLEDGE
Hospitalists should be able to:

  • Explain the anatomy and physiology of normal and pathologic cardiac tissues, including spatial relationships, vascular supply, automaticity, conduction, and autonomic innervations, and how these affect EKG interpretation.
  • Compare the diagnostic utility of rhythm strips and continuous monitoring (telemetry) with that of standard 12-lead EKGs.
  • Explain the indications for ordering a standard EKG, right-sided EKG, and telemetry monitoring.
  • Describe the characteristics of electrocardiographic waveforms in different leads on an EKG tracing.  
  • Describe the relevant components of the EKG tracing.
  • Explain the effect of cardiovascular, metabolic, toxic, and systemic disease processes on cardiac electrical potentials of the EKG. 
  • Explain the limitations of various EKG and telemetry findings, including computerized interpretations.

SKILLS
Hospitalists should be able to:  

  • Demonstrate correct lead placement.
  • Accurately measure and interpret the atrial and ventricular rates, voltages, and intervals of EKG tracings.
  • Recognize normal EKG findings, including variations associated with demographics, artifact, lead placement, and other technical problems. 
  • Recognize and categorize abnormal EKG findings, including abnormalities in cardiac tissue health, conduction, automaticity, anatomy, and manifestations of noncardiac disease.
  • Identify paced rhythms and describe the limitations of related EKG interpretations.
  • Synthesize EKG and telemetry data with other clinical information to risk stratify patients and develop a clinical plan.
  • Determine the need for specialist intervention on the basis of urgency and patient risk. 
  • Communicate with patients and families to explain EKG results and how the findings influence the care plan. 

ATTITUDES
Hospitalists should be able to:

  • Prioritize prompt interpretation of EKGs.
  • Recognize the value of comparing the current EKG with historical EKG tracings, when available. 
  • Adopt a standardized and consistent approach to interpreting EKG tracings and reviewing telemetry data. 
  • Consult and work collaboratively with cardiologists in interpreting complex EKG tracings and in ordering further diagnostic studies or procedures on the basis of EKG interpretation. 

SYSTEM ORGANIZATION AND IMPROVEMENT
To improve quality and efficiency within their organizations, hospitalists should:

  • Lead, coordinate, and/or participate in initiatives to optimize resource use, including the appropriate use and duration of telemetry monitoring.
  • Lead, coordinate, and/or participate in efforts to expedite acquisition and interpretation of EKGs for hospitalized patients in a timely manner.

2.4 EMERGENCY PROCEDURES

In hospital medicine, emergency procedures refer to a set of immediate actions that may be necessary to stabilize or resuscitate patients with impending or established cardiorespiratory arrest or other major organ failure. Such actions may include cardiopulmonary resuscitation using advanced cardiac life support (ACLS) protocols and advanced airway management via endotracheal intubation. In addition, patients may require short-term advanced respiratory support such as mechanical ventilation until their transition to a higher level of care (for example, to an intensive care unit) or until their recovery from a short-term critical illness. Hospitalists care for patients admitted with critical illnesses, or who may become critically ill during the course of their hospitalization, and thus need to perform and supervise such emergency procedures. Hospitalists should lead efforts that ensure the delivery of timely, effective, and standardized responses to such inpatient emergencies.  

CARDIOPULMONARY RESUSCITATION
KNOWLEDGE

Hospitalists should be able to: 

  • Describe the normal anatomy of the upper airway, thorax, heart, and lungs.
  • Describe the clinical findings or disease processes that require cardiopulmonary resuscitation and advanced life support.
  • Describe clinical and electrocardiographic findings that affect cardiopulmonary arrest outcome.
  • List indicated laboratory and other diagnostic testing during cardiopulmonary distress or arrest and immediately following successful resuscitation.
  • Distinguish between current basic life support (BLS) and ACLS protocols, including selection of interventions appropriate to the clinical situation.
  • Describe the equipment needed to manage the airway, identify cardiac rhythms, and perform defibrillation.
  • Describe cardiac rhythms and clinical situations that require immediate defibrillation.    
  • Describe the uses of and mechanisms of action of medications used during ACLS implementation. 
  • Explain the indications for procedural interventions that may be used during the course of resuscitation.
  • Define return of spontaneous circulation.
  • Describe postresuscitation care protocols.
  • Recognize the indications for emergent specialty consultation when available, which may include otolaryngology, surgery, or critical care medicine. 

SKILLS 
Hospitalists should be able to:

  • Promptly identify acute cardiopulmonary distress or arrest and call for assistance.
  • Assess the patient and the clinical situation in a timely manner and attempt to identify the cause and other complicating factors.
  • Elicit additional pertinent information from available sources such as the patient’s family, other healthcare providers, and the medical record when available.
  • Interpret cardiac rhythms and other diagnostic indicators.
  • Perform, coordinate, and lead prompt and effective resuscitation in a manner consistent with current ACLS protocols.
  • Facilitate interactions between healthcare professionals regarding the roles that each will perform during the resuscitation effort. 
  • Synthesize diagnostic information to deliver medications and/or defibrillation and perform procedures required during resuscitation efforts.
  • Maintain safety of all team members by taking necessary precautions and using appropriate protective wear.
  • Evaluate the quality of ongoing resuscitation efforts and implement changes as necessary.
  • Discontinue resuscitation efforts when interventions have been unsuccessful and continued efforts are deemed medically futile. 
  • Arrange for appropriate care transitions following successful resuscitation. 
  • Review the resuscitation documentation for accuracy immediately following the event. 
  • Communicate with families to explain the procedures performed as well as outcomes and next steps in management.

ATTITUDES
Hospitalists should be able to:

  • Review and respect the advance directives and resuscitation choices of patients and/or their surrogates. 
  • Rapidly respond to emergencies without distraction.
  • Appreciate the value of spiritual support services during and following resuscitation efforts. 

ENDOTRACHEAL INTUBATION
KNOWLEDGE 

Hospitalists should be able to:

  • Describe the normal anatomy of the upper airway.
  • Describe clinical findings or disease processes that may require securing an airway.
  • Describe the indications, contraindications, benefits, and risks of endotracheal intubation.
  • Describe the necessary equipment and medications required for routine and complicated intubations.
  • Describe the process of endotracheal intubation from laryngoscope assembly to assessment of tube placement.  
  • Differentiate among alternatives to endotracheal intubation.
  • Recognize indications for appropriate specialty consultation for difficult or unsuccessful intubations or when clinician experience level precludes intubation trial. 

SKILLS 
Hospitalists should be able to:

  • Identify patients who may benefit from endotracheal intubation. 
  • Assess patients for degree of procedural complexity and complication risk. 
  • Perform prompt and safe endotracheal intubation using techniques selective to the patient’s anatomy and condition. 
  • Determine and place the endotracheal tube at an appropriate depth in the airway.
  • Confirm endotracheal tube placement by approved methods and make adjustments as necessary.
  • Use an alternative suitable airway control for patients with difficult or unsuccessful intubations. 
  • Maintain safety of all team members by taking necessary precautions and using appropriate protective wear. 
  • Evaluate for procedural complications and adopt necessary measures.
  • Communicate with families to explain the procedures performed as well as outcomes and next steps in management.

ATTITUDES 
Hospitalists should be able to:

  • Review and respect the advance directives and resuscitation choices of patients and/or their surrogates. 
  • Rapidly respond to emergencies without distraction.
  • Demonstrate awareness of and ability to address periprocedural emotional and physical discomfort.

SHORT-TERM MECHANICAL VENTILATION
KNOWLEDGE
 
Hospitalists should be able to:

  • Describe the normal anatomy of the respiratory system.
  • Describe disease processes that lead to respiratory failure.
  • Describe the indications, benefits, and risks of mechanical ventilation.
  • Describe indications and contraindications for noninvasive ventilation in selected patients.
  • Explain the role of arterial blood gas analysis in the management of ventilated patients.
  • Explain the basic components and workings of a ventilator. 
  • Describe available modes of ventilation and process of selection of suitable ventilator settings.
  • List causes of ventilator alarms.
  • Recognize the indications for specialty consultation, which may include critical care medicine. 

SKILLS
Hospitalists should be able to:

  • Use nursing and respiratory therapy reports, physical examination findings, and ventilator data to identify complications due to mechanical ventilation.
  • Provide adequate sedation, comfort management, and paralysis when indicated for patients requiring mechanical ventilation. 
  • Select and adjust the ventilator mode and settings on the basis of the disease process, patient factors, ventilator data, and laboratory findings.
  • Institute indicated interventions when complications of mechanical ventilation are encountered.
  • Order and interpret laboratory and imaging studies on the basis of changes in the patient’s clinical status.
  • Evaluate and treat underlying conditions leading to respiratory failure.
  • Implement evidence-based interventions known to reduce risk of ventilator-associated complications. 
  • Communicate with families to explain the procedures performed as well as outcomes and next steps in management.

ATTITUDES 
Hospitalists should be able to:

  • Review and respect the advance directives and resuscitation choices of patients and/or their surrogates. 
  • Rapidly respond to emergencies without distraction.
  • Appreciate the value of spiritual support services during and following resuscitation efforts.

SYSTEM ORGANIZATION AND IMPROVEMENT FOR EMERGENCY PROCEDURES
To improve efficiency and quality within their organizations, hospitalists should:

  • Lead, coordinate, and/or participate in multidisciplinary teams, which may include critical care nurses, respiratory therapists, and critical care and emergency physicians, to establish ongoing training to ensure high-quality performance of emergency procedures.      
  • Lead, coordinate, and/or participate in multidisciplinary efforts to review antecedent events to identify changes in clinical status that, if promptly identified and acted upon, may have prevented the emergency intervention.  
  • Facilitate appropriate organization and consolidation of equipment in multiple identifiable and accessible locations in the hospital for the optimal performance of emergency procedures. 
  • Lead, coordinate, and/or participate in evaluation of resuscitation and mechanical ventilation outcomes and identify and implement improvement initiatives.

2.5 LUMBAR PUNCTURE

Lumbar puncture is a procedure during which a needle is inserted into the subarachnoid space to obtain cerebrospinal fluid (CSF) for laboratory analysis to assess for acute or chronic central nervous system (CNS) disease processes. It is one of the more commonly performed bedside procedures in hospitalized patients and is often considered the cornerstone for the diagnosis of acute bacterial, fungal, and viral CNS infections and subarachnoid hemorrhage.1 Hospitalists may suspect the presence of such conditions during their patient assessment and should use clinical expertise and evidence-based decision-making to determine whether a lumbar puncture is required in the diagnosis and management of the patient’s illness. 

KNOWLEDGE
Hospitalists should be able to:

  • Describe the anatomy of the spinal column and the spinal cord and identify anatomic landmarks to guide proper entry point for lumbar puncture.
  • Explain the indications and contraindications for lumbar puncture including potential risks, benefits, and complications.
  • List the indications for CNS imaging before lumbar puncture.
  • Explain the appropriate diagnostic tests necessary to characterize CSF on the basis of the clinical presentation.
  • Recognize the indications for specialty consultation, which may include interventional radiology, infectious disease, or neurology. 

SKILLS
Hospitalists should be able to:

  • Assess patients for increased risk of complications and use appropriate preventive measures.
  • Select the necessary equipment to perform a lumbar puncture at the bedside. 
  • Demonstrate the optimal patient positioning to safely perform a lumbar puncture.
  • Demonstrate proficiency in performance of lumbar puncture.
  • Perform a time-out before the procedure. 
  • Use appropriate sterile technique and necessary precautions throughout the procedure to minimize the risk of complications for patients and providers. 
  • Order and interpret the results of CSF analyses to determine an appropriate management plan.
  • Anticipate and manage complications of lumbar puncture after the procedure, which may include bleeding, headache, or infection.
  • Obtain informed consent and effectively communicate with patients and families to explain the procedure, its expected diagnostic or therapeutic benefits, and potential complications. 

ATTITUDES
Hospitalists should be able to:

  • Demonstrate awareness of and ability to address periprocedural emotional and physical discomfort. 

SYSTEM ORGANIZATION AND IMPROVEMENT
To improve efficiency and quality within their organizations, hospitalists should:

  • Lead, coordinate, and/or participate in multidisciplinary initiatives to optimize resource use.
  • Lead, coordinate, and/or participate in efforts to develop strategies to minimize institutional complication rates.
  • Lead, coordinate, and/or participate in patient safety and quality improvement programs to monitor hospitalists’ performance and/or supervision of procedural competence.
  • Lead, coordinate, and/or participate in patient safety programs designed to coordinate care transition and the handoff of pending test results at the time of hospital discharge.
  • Collaborate with emergency physicians to develop protocols for rapid identification and evaluation of patients with suspected CNS infections, bleeding, and other life-threatening conditions.

References
1.     Mayo Clinic. Lumbar puncture (spinal tap). Available at: www.mayoclinic
.org/tests-procedures/lumbar-puncture/basics/definition/prc-20012679. 
Accessed June 2015.

2.6 PARACENTESIS

Paracentesis, the aspiration of fluid from the peritoneal cavity, is frequently performed in the diagnosis and management of patients with ascites from various causes. Currently, paracentesis may be underused in hospitalized patients with ascites, and evidence suggests that this procedure may be associated with reduced short-term mortality.1 Hospitalists may identify ascites during the history and physical examination and should use clinical expertise and evidence-based decision-making to determine whether paracentesis is indicated in the diagnosis or management of the patient’s illness.

KNOWLEDGE 
Hospitalists should be able to:

  • Describe the normal anatomy of the abdomen and pelvis.
  • Define and differentiate pathophysiologic processes that may lead to the development of ascites.
  • Explain indications and contraindications for paracentesis including potential risks, benefits, and complications.
  • Describe the accuracy of physical examination maneuvers in the evaluation of ascites.
  • Differentiate among the indications for a diagnostic and therapeutic paracentesis.
  • Describe the indications for the use of additional modalities such as ultrasonography to assess and/or guide paracentesis.
  • Explain the appropriate diagnostic tests to accurately characterize ascitic fluid.
  • Define the serum ascites albumin gradient and its role in the evaluation of ascites.
  • Explain the indications for administration of albumin in conjunction with paracentesis.
  • Recognize the indications for specialty consultations, which may include interventional radiology or gastroenterology. 

SKILLS
Hospitalists should be able to:

  • Elicit a thorough and relevant history to identify comorbid conditions and risk factors for the development or complications of ascites.
  • Perform a physical examination to evaluate for signs of the primary condition responsible for the development of ascites.
  • Assess patients for increased risk of complications and use appropriate preventive measures.
  • Demonstrate the optimal patient positioning during paracentesis.
  • Select the necessary equipment to perform a paracentesis safely at the bedside.
  • Perform a time-out before the procedure. 
  • Use appropriate sterile technique and necessary precautions throughout the procedure to minimize the risk of complications for patients and providers.
  • Order and interpret the results of ascitic fluid analyses to determine an appropriate management plan.
  • Anticipate and manage complications of paracentesis after the procedure, which may include bleeding, leakage, or infection.
  • Obtain informed consent and effectively communicate with patients and families to explain the procedure, its expected diagnostic or therapeutic benefits, and potential complications.

ATTITUDES
Hospitalists should be able to:

  • Demonstrate awareness of and ability to address periprocedural emotional and physical discomfort.

SYSTEM ORGANIZATION AND IMPROVEMENT 
To improve efficiency and quality within their institutions, hospitalists should:

  • Lead, coordinate, and/or participate in multidisciplinary initiatives to optimize resource use.
  • Lead, coordinate, and/or participate in efforts to develop strategies to minimize institutional complication rates of paracentesis.
  • Lead, coordinate, and/or participate in patient safety and quality improvement programs to monitor hospitalists’ performance and/or supervision of procedural competence.
  • Lead, coordinate, and/or participate in patient safety programs designed to coordinate care transition and the handoff of pending test results at the time of hospital discharge.

References
1.     Orman ES, Hayashi PH, Bataller R, Barritt AS 4th. Paracentesis is associated with reduced mortality in patients hospitalized with cirrhosis and ascites. Clin Gastroenterol Hepatol. 2014;12(3):496-503.

2.7 THORACENTESIS

Thoracentesis is a procedure involving the withdrawal of fluid from the pleural cavity to determine the etiology of or to treat the effects of a pleural effusion. It is a frequently performed bedside procedure for both diagnostic and therapeutic purposes. The most common clinically important complication is pneumothorax. With the advent of ultrasound guidance, the rate of pneumothorax after thoracentesis in nonventilated patients is less than 2%.1-3 Hospitalists may identify pleural effusions during the history and physical examination and should use clinical expertise and evidence-based decision-making to determine whether a thoracentesis is required in the diagnosis and management of the patient’s illness.  

KNOWLEDGE
Hospitalists should be able to:

  • Describe the normal anatomy of the chest wall, thorax, and lung.
  • Define and differentiate the disease processes that may lead to the development of pleural effusion.
  • Define and differentiate transudative from exudative pleural effusions. 
  • Explain indications and contraindications of thoracentesis and its potential risks and complications. 
  • Describe the proper use of ultrasonography in guiding thoracentesis.
  • Explain the appropriate diagnostic tests to accurately characterize pleural fluid and identify the underlying disease process.
  • Recognize indications for specialty consultations, which may include interventional radiology, pulmonary medicine, infectious disease, or cardiothoracic surgery. 

SKILLS
Hospitalists should be able to:

  • Elicit a thorough and relevant medical history to identify potential disease processes and risk factors for the development of pleural effusions.
  • Perform a chest examination including specific maneuvers to assess for the presence and size of the pleural effusion.
  • Demonstrate the optimal patient position for safely performing a thoracentesis.
  • Perform a time-out before the procedure. 
  • Perform a competent diagnostic and/or therapeutic thoracentesis with standard use of ultrasound guidance.  
  • Select the necessary equipment to perform a thoracentesis safely at the bedside.
  • Use appropriate sterile technique and necessary precautions throughout the procedure to minimize the risk of complications for patients and providers. 
  • Order and interpret the results of pleural fluid analyses to determine an appropriate management plan.
  • Anticipate and manage complications of thoracentesis after the procedure, which may include pneumothorax, bleeding, leakage, or infection.
  • Obtain informed consent and effectively communicate with patients and families to explain the procedure, its expected diagnostic or therapeutic benefits, and potential complications. 

ATTITUDES
Hospitalists should be able to:

  • Demonstrate awareness of and ability to address periprocedural emotional and physical discomfort. 

SYSTEM ORGANIZATION AND IMPROVEMENT
To improve efficiency and quality within their organizations, hospitalists should:

  • Lead, coordinate, and/or participate in multidisciplinary initiatives to optimize resource use.
  • Lead, coordinate, and/or participate in efforts to develop strategies to minimize institutional complication rates of thoracentesis.
  • Lead, coordinate, and/or participate in patient safety and quality improvement programs to monitor hospitalists’ performance and/or supervision of procedural competence.
  • Lead, coordinate, and/or participate in patient safety programs designed to coordinate care transition and the handoff of pending test results at the time of hospital discharge.

References
1.     Cavanna L, Mordenti P, Berle R, Palladino MA, Biasini C, Anselmi E, et al. Ultrasound guidance reduces pneumothorax rate and improves safety of thoracentesis in malignant pleural effusion: report on 445 consecutive patients with advanced cancer. World J Surg Oncol. 2014;12:139.
2.     Duncan DR, Morgenthaler TI, Ryu JH, Daniels CE. Reducing iatrogenic risk in thoracentesis: establishing best practice via experiential training in a zero-risk environment. Chest. 2009;135(5):1315-1320.
3.     Mercaldi CJ, Lanes SF. Ultrasound guidance decreases complications and improves the cost of care among patients undergoing thoracentesis and paracentesis. Chest. 2013;143(2):532-538
.

2.8 VASCULAR ACCESS

Vascular access involves inserting a catheter into an appropriate blood vessel to measure useful diagnostic parameters, draw blood for diagnostic testing, and/or provide specific therapeutic interventions. Many hospitalized patients require vascular access, and hospitalists differentiate patients who simply need peripheral venous access from those who require more invasive types of arterial or central venous access. Approximately 8% of hospitalized patients require central venous access, and more than 5 million central venous catheters are inserted annually in the United States.1,2 Complications of vascular catheters such as infection, venous thrombosis, arrhythmia, and vascular injury can prolong hospital stays and increase morbidity and mortality. Of the 50,000 to 100,000 catheter-related bloodstream infections that occur annually in United States, approximately 90% are due to central venous catheters.3-5 Hospitalists advocate for patients to determine the most appropriate type of vascular access on the basis of the patient’s diagnostic and therapeutic requirements and overall clinical condition. 

KNOWLEDGE
Hospitalists should be able to:

  • Name the various locations for peripheral venous access and describe the normal vasculature and surrounding anatomy of the site chosen for access. 
  • Name the various locations for arterial or central venous access and describe the normal vasculature and surrounding anatomy of the site chosen for vascular access. 
  • Identify absolute and relative contraindications to placement of arterial or central venous access at specific sites. 
  • Describe the clinical findings or disease processes that require arterial or central venous access.
  • Explain the indications for additional modalities such as ultrasonography in vascular access placement.
  • Explain indications and contraindications of the various arterial or central venous access procedures.
  • Describe and differentiate the potential risks and complications of individual vascular access procedures on the basis of the site chosen and other risk factors.
  • Recognize the indications for specialty consultation, which may include interventional radiology, surgery, or critical care medicine. 

SKILLS
Hospitalists should be able to:

  • Elicit a thorough and relevant medical history to identify comorbid conditions and risk factors for complications related to arterial or central venous access placement.
  • Assess patients for increased risk of complications and use appropriate preventive measures.
  • Perform a directed physical examination of the site(s) intended for vascular access.
  • Perform specific maneuvers to evaluate for collateral flow for arterial access procedures.
  • Select the necessary equipment to perform the indicated vascular access procedure at the bedside.
  • Properly position the patient and identify anatomic landmarks to obtain vascular access.
  • Perform a time-out before the procedure. 
  • Use appropriate sterile technique and necessary precautions throughout the procedure to minimize the risk of complications for patients and providers. 
  • Anticipate and manage the complications of vascular access procedures, which may include infection, thrombotic complications, and mechanical complications.
  • Promote the use of peripheral venous access over central venous access whenever possible. 
  • Evaluate the need for all central venous catheters and arterial catheters on a regular basis and limit their use accordingly.
  • Communicate with patients and families to explain the indications and alternatives to vascular access. 
  • Obtain informed consent and effectively communicate with patients and families to explain the procedure, its expected diagnostic or therapeutic benefits, and potential complications. 
  • Educate patients and their families regarding the care of long-term vascular access. 
  • Arrange appropriate care for patients being discharged with long-term vascular access. 

ATTITUDES
Hospitalists should be able to:

  • Demonstrate awareness of and ability to address periprocedural emotional and physical discomfort. 

SYSTEM ORGANIZATION AND IMPROVEMENT 
To improve efficiency and quality within their organizations, hospitalists should:

  • Lead, coordinate, or and/or participate in multidisciplinary initiatives to optimize resource use.
  • Lead, coordinate, and/or participate in efforts to develop strategies to minimize institutional complication rates of vascular access.
  • Lead, coordinate, and/or participate in patient safety and quality improvement programs to monitor hospitalists’ performance and/or supervision of procedural competence.
  • Lead, coordinate, or and/or participate in implementation of standardized protocols for catheter placement and maintenance care.

References
1.     McGee DC, Gould MK. Preventing complications of central venous catheterization. N Engl J Med. 2003;348(12):1123-1133.
2.     Ruesch S, Walder B, Tramer MR. Complications of central venous catheters: internal jugular versus subclavian access—a systematic review. Crit Care Med. 2002;30(2):454-460.
3.     Martone WJ, Gaynes RP, Horan TC, Danzig L, Emori TG, Monnet D, et al. National Nosocomial Infections Surveillance (NNIS) semiannual report, May 1995. A report from the National Nosocomial Infections Surveillance (NNIS) System. Am J Infect Control. 1995;23(6):377-385.
4.     Mermel LA. Prevention of intravascular catheter-related infections. Ann Intern Med. 2000;132(5):391-402.
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