The Core Competencies in Hospital Medicine—Clinical Conditions 2023 Update

Acute Coronary Syndrome Acute Kidney Injury Acute Pancreatitis Alcohol Withdrawal Asthma Cardiac Arrhythmia Chronic Obstructive Pulmonary Disease Community-Acquired Pneumonia Decompensated Cirrhosis Delirium and Dementia Diabetes Mellitus Gastrointestinal Bleed Heart Failure Hypertension in Hospitalized Patients Hyponatremia Nosocomial Pneumonia (previously titled Hospital-Acquired Pneumonia) Opioid and Other Substance Use Disorders Pain Management Perioperative Medicine Sepsis Skin and Soft Tissue Infections Stroke Syncope Urinary Tract Infection Venous Thromboembolism 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). Heart disease, including coronary artery disease (CAD), is the leading cause of mortality in the United States.1 Urgent evaluation and treatment is critical for improving outcomes.2 Hospitalists diagnose, risk stratify, and initiate early management of patients with ACS. Hospitalists provide leadership for multidisciplinary teams that optimize the quality of inpatient care, maximize opportunities for patient education, and efficiently use resources. In addition, hospitalists initiate secondary preventive measures and facilitate adherence to outpatient medical regimens. Define and differentiate UA, NSTEMI, and STEMI. Describe the pathophysiologic processes and variable clinical presentations of patients with ACS. Distinguish ACS from other cardiac and noncardiac conditions that may mimic this disease process. Describe the use of cardiac biomarkers in the diagnosis of ACS, including timing of testing and the effects of renal disease and other conditions (such as pulmonary embolism or sepsis) on cardiac biomarker levels. Describe the role, diagnostic accuracy, and limitations of noninvasive cardiac tests in the diagnosis and management of ACS. Explain indications for and risks associated with cardiac catheterization. Describe the indications for early specialty consultation, which may include cardiology and cardiothoracic surgery. List the major and minor risk factors predisposing patients to CAD. Explain the value and use of validated risk stratification tools including evidence-based indications for hospitalization of patients with chest pain. Explain indications and contraindications for fibrinolytic therapy. Explain indications, contraindications, and mechanisms of action of pharmacologic agents that are used pre- and postrevascularization. Describe factors that indicate the need for early invasive interventions such as angiography, percutaneous coronary intervention, and coronary artery bypass grafting. Describe the optimal timeframe for coronary reperfusion when indicated. Identify clinical, laboratory, and imaging studies that indicate the severity of acute events and inform the expected prognosis. Describe appropriate timing and thresholds for hospital discharge, including specific measures of clinical stability for safe transition of care. Elicit a thorough and relevant medical history with emphasis on presenting symptoms and patient risk factors for CAD. Perform a physical examination with emphasis on the cardiovascular and pulmonary systems and recognize clinical signs of ACS and disease severity. Diagnose ACS through interpretation of expedited testing including history, physical examination, electrocardiogram, chest radiograph, and biomarkers. Use risk stratification tools to determine appropriate site of testing and treatment for patients presenting with chest pain and communicate recommendations to patients and families. Synthesize results of history, physical examination, electrocardiography, laboratory and imaging studies, and risk stratification tools to determine therapeutic options and formulate an evidence-based treatment plan. Identify patients who may benefit from fibrinolytic therapy and/or early revascularization in a timely manner, and activate appropriate teams accordingly. Treat patients' symptoms of chest pain, anxiety, and other discomfort associated with ACS. Initiate immediate indicated therapies when patients display symptoms and signs of decompensation. Anticipate and address 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. Assess patients with suspected ACS in a timely manner, identify the level of care required, and manage or comanage the patient with the primary requesting service. Communicate with patients and families to explain the history and prognosis of their cardiac disease. Communicate with patients and families to explain noninvasive tests and procedures and their indications, benefits, and limitations and to obtain informed consent. Communicate with patients and families to explain the use and potential adverse effects of pharmacologic agents. Initiate secondary preventive measures before discharge, which may include smoking cessation, dietary modification, and evidence-based medical therapies. Communicate with patients and families to explain the goals of care, discharge instructions, and management after hospital discharge. Coordinate and document the treatment plan and provide clear discharge instructions for postdischarge clinicians responsible for monitoring response to treatment. Employ a multidisciplinary approach, which may include nursing, nutrition, rehabilitation, and social services, in the care of patients with ACS that begins at admission and continues through all care transitions. Follow evidence-based recommendations, protocols, and risk-stratification tools for the treatment of ACS. Lead, coordinate, and/or participate in efforts to develop protocols to rapidly identify patients with ACS and minimize time to intervention. Lead, coordinate, and/or participate in initiatives to create optimal care pathways for patients with chest pain based on available evidence-based risk stratification tools. Implement systems to ensure hospital-wide adherence to national standards and document those measures as specified by recognized organizations (e.g., The Joint Commission, American Heart Association, American College of Cardiology, Agency for Healthcare Research and Quality). Lead, coordinate, and/or participate in multidisciplinary initiatives to promote patient safety and optimize resource use, which may include order sets for ACS and chest pain. Lead, coordinate, and/or participate in efforts to educate staff on the importance of smoking cessation counseling and other preventive measures. Integrate outcomes research, institution-specific laboratory policies, and hospital formulary to create indicated and cost-effective diagnostic and management strategies for patients with ACS. Mozaffarian D, Benjamin EJ, Go AS, et al. American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics—2015 update: a report from the American Heart Association. Circulation. 2015;131(4):e29-e322. Amsterdam EA, Wenger NK, Brindis RG, et al. AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;130:e344-e426. Emergency procedures—Cardiopulmonary resuscitation Electrocardiogram interpretation and telemetry monitoring Acute kidney injury (AKI) 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. AKI is common among hospitalized patients.1 AKI may present in isolation, develop as a complication of other comorbid illness, or result as a deleterious adverse effect of treatment or diagnostic interventions. It is associated with elevated mortality, multiorgan failure, and length of stay.2 Hospitalists facilitate the expeditious evaluation and management of AKI to improve patient outcomes, optimize resource use, and reduce length of stay. Hospitalists can also advocate and initiate preventive strategies to reduce the incidence of secondary AKI. Define AKI based on accepted clinical criteria. Describe the symptoms and signs of AKI. Describe and differentiate pathophysiologic causes of AKI including prerenal, intrinsic renal, and postrenal processes. Differentiate among the causes of prerenal, intrinsic renal, and postrenal types of AKI. Describe the differences in clinical course for various types of AKI. Describe a logical sequence of indicated tests required to evaluate the etiology based on the type of AKI. Differentiate between low- and high-value tests available to evaluate the etiologies of AKI. List common potentially nephrotoxic agents that can cause or worsen AKI. Explain the indications, contraindications, and mechanisms of action of the interventions used to treat AKI. Explain the indications, contraindications, benefits, and risks of renal replacement therapy. Identify acute tubular necrosis as a subset of AKI with a worse prognosis. Describe the various levels of AKI, understand the indications for specialty consultation and the role of nephrology and urology specialists. Describe criteria, including specific measures of clinical stability, that must be met before discharging patients with AKI. Explain the specific goals that should be met to ensure safe transitions of care for patients with AKI. Assess patients with suspected AKI in a timely manner and manage or comanage the patient with the primary requesting service. Elicit a thorough and relevant medical history with emphasis on factors predisposing or contributing to the development of AKI. Perform a thorough medication reconciliation including prescription and over-the-counter medications, herbal remedies, nutritional supplements, and illicit drugs to identify common potential nephrotoxins. Perform a physical examination to assess volume status and to identify underlying comorbid states that may predispose to the development of AKI. Order and interpret results of indicated diagnostic studies that may include urinalysis and microscopic sediment analysis, urinary protein excretion, serologic evaluation, and renal imaging to determine the etiology of AKI. Develop a treatment plan appropriate for the etiology and severity of the AKI which may include fluid management, medication adjustment, nutritional recommendations, procedures, or consultation. Diagnose and treat common complications of AKI, such as electrolyte abnormalities, acidemia, hypertensive crisis, underlying infection, and volume overload. Calculate estimated creatinine clearance for medication dosage adjustments when indicated. Identify patients at risk for developing AKI and institute appropriate preventive measures. Communicate with patients and families to explain the cause and prognosis of AKI. Communicate the role of intravascular contrast agents for radiographic tests and procedures including the benefits and potential adverse effects. Communicate with patients and families to explain the goals of care, discharge instructions, and management after hospital discharge. Coordinate and document the treatment plan and provide clear discharge instructions for postdischarge clinicians responsible for monitoring response to treatment. Employ a multidisciplinary approach, which may include nursing, nutrition, and pharmacy services, in the care of patients with AKI that begins at admission and continues through all care transitions. Follow evidence-based recommendations, protocols, and risk-stratification tools for the treatment of AKI. Advocate for, establish, and support initiatives to reduce the incidence of iatrogenic AKI. Lead, coordinate, and/or participate in multidisciplinary teams (including nephrology, nursing, pharmacy, and nutrition services) to improve processes that facilitate early identification of AKI and improved patient outcomes. Lead, coordinate, and/or participate in multidisciplinary initiatives to promote patient safety and optimize management strategies for AKI. Makris K, Spanou L. Acute kidney injury: definition, pathophysiology and clinical phenotypes. Clin Biochem Rev. 2016;37(2):85-98. See EJ, Jayasinghe K, Glassford N, et al. Long-term risk of adverse outcomes after acute kidney injury: a systematic review and meta-analysis of cohort studies using consensus definitions of exposure. Kidney Int. 2019;95(1):160-172. doi:10.1016/j.kint.2018.08.036 The acute inflammation of the pancreas is known as acute pancreatitis (AP). It is diagnosed based on a combination of clinical, biochemical or radiologic evidence of acute pancreatic inflammation. AP is a leading gastrointestinal cause of hospitalization in the United States.1 The leakage of activated pancreatic enzymes, microcirculatory injury, and the release of inflammatory cytokines lead to pancreatic damage and necrosis. When severe, it may trigger a systemic inflammatory response (SIRS), resulting in multiorgan dysfunction. Most cases of AP are mild and self-limited, hospitalizations brief, and patients improving quickly, usually within the first 48–72 h. However, in up to 20% of patients, AP can be moderately severe, characterized by transient organ failure or local or systemic complications, or severe when there is persistent organ failure or death. Hospitalists facilitate the expeditious evaluation and management of AP in coordination with specialists when necessary to improve patient outcomes.2 Define acute pancreatitis and describe its pathogenesis and natural history. Describe common symptoms and signs of AP. Differentiate the clinical features of AP from other common causes of upper abdominal pain. Describe the common and rare causes of AP, including biliary, toxic, metabolic, infectious, vascular, traumatic, anatomic, and iatrogenic causes. Describe the clinical, laboratory, and radiologic criteria for diagnosing AP. Describe the classification system for AP and differentiate between the categories of disease severity. Describe the local and systemic complications of AP and long-term sequela. Discuss the utility of clinical signs, laboratory tests, radiologic findings, and clinical scoring systems for diagnosing and predicting the severity of AP. Describe the role and timing of goal-directed fluid management in the initial management of AP and the risks associated with underhydration and overhydration. Discuss the importance of optimal pain control in patients with pancreatitis-related abdominal pain. Describe the role, route, and timing of nutritional support in patients with moderately severe and severe pancreatitis. Describe the indications for specialty consultation, including gastroenterology, surgery, nutrition services, and social work. Describe the indications for patient transfer to a higher level of care, such as intensive care or interfacility transfer to a center with multidisciplinary expertise. Describe criteria, including specific clinical stability measures that must be met before discharging patients with AP. Discuss the modifiable and nonmodifiable risk factors predictive of hospital readmission and recurrent pancreatitis. Elicit a thorough and relevant medical history to identify the etiology and predisposing factors contributing to AP. Perform a physical examination to assess findings suggestive of the etiology disease severity (such as volume depletion and SIRS criteria), and complications of AP. Order and interpret results of indicated diagnostic studies that may include measurement of serum lipase, abdominal ultrasound, computed tomography, and magnetic resonance imaging. Develop a treatment plan appropriate for the severity of AP, including optimal fluid management, pain control, nutritional support, procedures, and consultation. Perform timely clinical reassessments and utilize evidence-based scoring systems within the first 48–72 h to monitor and guide the response to therapy and assign appropriate levels of care. Develop a management plan to determine the etiology of AP and treat associated clinical syndromes such as active biliary disease, hypertriglyceridemia, hypercalcemia, or alcohol withdrawal and dependence. Diagnose and treat common local and systemic complications of AP (such as necrotizing pancreatitis, pancreatic pseudocyst, retroperitoneal hemorrhage, intra-abdominal compartment syndrome, renal and respiratory dysfunction, and other organ dysfunction). Describe the role of antibiotic therapy in patients with AP. Identify patients at risk for developing recurrent disease and long-term sequela. Communicate with patients and families to explain the cause and prognosis of AP. Communicate the role of nutrition, including the timing and type of feeding in patients with AP. Communicate with patients and families to explain the goals of care, discharge instructions, and management after hospital discharge. Coordinate and document the treatment plan and provide clear discharge instructions for postdischarge clinicians responsible for monitoring treatment response. Employ a multidisciplinary approach, which may include specialist, nursing, nutrition, and pharmacy services, in the care of patients with AP that begins at admission and continues through all care transitions. Identify the need for subsequent evaluation of patients with AP without a clear etiology despite initial testing. Advocate for, establish, and support initiatives to reduce the risk of recurrent pancreatitis for patients with modifiable risk factors. Lead, coordinate, and/or participate in multidisciplinary teams (including gastroenterology, surgery, radiology, intensive care, nursing, pharmacy, social work, and nutrition services) to improve processes that facilitate early identification and optimal management of AP, fewer complications, and improved patient outcomes. Peery AF, Crockett SD, Murphy CC, et al. Burden and cost of gastrointestinal, liver, and pancreatic diseases in the United States: update 2018. Gastroenterology. 2019;156(1):254-272. Dick, JF, III, Gardner, TB, Merrens, EJ. Acute pancreatitis: new developments and strategies for the hospitalist. J Hosp Med. 2016;11:724-729. Alcohol dependence is often a product of a combination of biopsychosocial influences, and in most cases, a multidisciplinary approach is necessary to successfully treat affected individuals. Alcohol withdrawal develops with sudden cessation or reduction in the use of alcohol. Withdrawal syndromes encompass a broad range of symptoms, from mild anxiety and tremulousness to more serious manifestations such as seizures or delirium tremens, which occurs in up to 5% of alcohol-dependent persons who undergo withdrawal.1 Hospitalists can lead their institutions in evidence-based treatment protocols that improve care, reduce costs and length of stay, and facilitate better outcomes in patients with substance-related withdrawal syndromes.2 Describe the pathophysiology of alcohol withdrawal. Describe the symptoms and signs associated with alcohol withdrawal. Describe the patient characteristics associated with poor outcomes and medical complications from alcohol dependence and withdrawal. Differentiate between alcohol intoxication and those of withdrawal. Distinguish alcohol withdrawal from other causes of delirium and other withdrawal syndromes. Describe the tests indicated to evaluate alcohol withdrawal. Identify patients at increased risk for complications of alcohol withdrawal. Explain indications, contraindications, and mechanisms of action of pharmacologic agents used to treat acute alcohol withdrawal. Identify the best setting within the hospital to initiate, monitor, evaluate, and treat patients with alcohol withdrawal. Elicit a thorough and relevant medical history with emphasis on substance use in a nonjudgmental manner. Perform a rapid, efficient, and targeted physical examination to assess for alcohol withdrawal and determine whether life-threatening comorbidities are present. Assess for common comorbidities in patients with a history of alcohol and drug use. Recognize circumstances in which patients do not have the capacity to make medical decisions as a result of impairment due to intoxication or withdrawal. Assess patients with suspected alcohol withdrawal in a timely manner, identify the level of care required, and manage or comanage patients with concomitant medical or surgical issues. Formulate a treatment plan, tailored to the individual patient, which may include pharmacologic agents and nutritional supplementation. Recognize potential complications in treatment of withdrawal syndrome, such as oversedation. Recommend the use of restraints and direct observation to ensure patient safety when appropriate. Use the acute hospitalization as an opportunity to counsel patients about abstinence, recovery, and the medical risks of alcohol use. Work with multidisciplinary teams to initiate preventive measures before discharge, including alcohol cessation measures. Communicate with patients and families to explain the goals of care, harm reduction strategies (e.g., abstinence/detoxification programs, etc.), discharge instructions, and management after hospital discharge. Coordinate and document the treatment plan and provide clear discharge instructions for postdischarge clinicians responsible for monitoring response to treatment. Employ a multidisciplinary approach, which may include Psychiatry, Pharmacy, Nursing, and Social Services, in the treatment of patients with alcohol use or dependency. Follow evidence-based national recommendations to guide diagnosis, monitoring, and treatment of withdrawal symptoms. Acknowledge and address bias when caring for patients and the role bias may play in medical decision making for patients with alcohol dependence. Establish and maintain an open dialog with patients and families regarding care goals and limitations. Lead, coordinate, and/or participate in the development and promotion of evidence-based guidelines and/or pathways that facilitate efficient and timely evaluation and treatment of patients with alcohol and drug withdrawal. Advocate for hospital resources to improve the care of patients with alcohol withdrawal and the environment in which the care is delivered. Establish relationships with and develop knowledge of community-based organizations that provide support to patients with alcohol use disorders. Promote awareness of substance use disorders and screening for them. Coordinate initiatives to address the increased risk of readmissions associated with substance and polysubstance abuse. Promote harm reduction efforts to reduce complications of alcohol use disorders. Chernyavsky S, Dharapak P, Hui J, et al. Alcohol and the hospitalized patient. Med Clin N Am. 2020;104(4):681-694. Wood E, Albarqouni L, Tkachuk S, et al. Will this hospitalized patient develop severe alcohol withdrawal syndrome? JAMA. 2018;320(8):825-833. Opioid and other substance use disorders Asthma is a chronic disease characterized by airway inflammation and reversible airflow limitation. It is one of the most common chronic conditions and leads to marked morbidity and mortality in hospitalized patients. In the United States, 1 in 12 people has asthma and nearly 50% of affected individuals experience an asthma exacerbation each year.1,2 Hospitalists are central to the provision of care for patients with asthma using evidence-based approaches to manage acute exacerbations and to prevent their recurrence.3,4 Hospitalists should strive to lead multidisciplinary teams to develop institutional guidelines and care pathways to improve efficiency and quality of care and to reduce readmission rates and morbidity and mortality from asthma. Define asthma and describe the pathophysiologic processes that lead to reversible airway obstruction and inflammation. Identify precipitants of asthma exacerbation, including environmental and occupational exposures. List risk factors for disease severity and death from asthma. Explain the clinical presentation of asthma exacerbation and differentiate it from other acute respiratory and nonrespiratory syndromes. Identify and classify asthma severity (e.g., intermittent, mild persistent, etc.). Describe the role of diagnostic testing, including peak flow monitoring, used for evaluation of asthma exacerbation. Describe evidence-based therapies for the treatment of asthma Explain indications, contraindications, and mechanisms of action of pharmacologic agents used to treat asthma. Describe the signs and symptoms of respiratory Explain the indications for invasive and noninvasive Describe the indications for consultation, which may include pulmonary and Explain goals for hospital discharge, including specific measures of clinical stability (e.g., asthma action for safe care Elicit a thorough and relevant medical history to identify of asthma and symptoms with asthma exacerbation. Perform a targeted physical examination to signs with asthma exacerbation, differentiate findings from those of other and assess severity. Communicate with patients and families to explain the natural history and prognosis of asthma. appropriate diagnostic studies to evaluate severity of asthma exacerbation and interpret the patients and families regarding the indications and appropriate use of use and appropriate evidence-based pharmacologic therapies asthma exacerbation. Recognize indications for transfer to the intensive care Communicate with patients and families to explain the importance of preventive measures (e.g., smoking cessation, of appropriate of environmental etc.). Communicate with patients and families to explain symptoms and signs that should medical Communicate with patients and families to explain discharge medications, potential adverse of and that patients of and peak flow before hospital discharge. to identify resources to obtain before hospital discharge. Develop and document an asthma action plan in for discharge. Communicate with patients and families to explain the goals of care, discharge instructions, and management after hospital discharge. Coordinate and document the treatment plan and provide clear discharge instructions for postdischarge clinicians responsible for monitoring response to treatment. Work with primary care and in making admission Employ a multidisciplinary approach, which may include pulmonary and respiratory nursing, and social services, in the care of patients with asthma exacerbation. Follow evidence-based recommendations for the treatment of patients with asthma to and develop order and pathways that facilitate use of evidence-based strategies for asthma exacerbation in the and with goals of improving outcomes, length of stay, and Lead, coordinate, and/or participate in and adherence which are for long-term treatment. Lead, coordinate, and/or participate in efforts to educate staff on the importance of smoking cessation counseling and other preventive measures. Lead, coordinate, and/or participate in multidisciplinary initiatives to promote patient safety and optimize cost-effective diagnostic and management strategies for patients with asthma. for Disease and for Asthma in the for Disease and Asthma and of Asthma J, S, Acute and treatment. J Clin management of hospitalized patients with asthma or chronic pulmonary disease. Hosp Med Chronic pulmonary disease Cardiac are a of conditions characterized by an heart or cardiac can cause or may result from complications Cardiac are one of the most common for inpatient is the most common cardiac and is associated with an increased risk for heart failure, and Hospitalists identify and treat all types of and often develop institutional protocols to improve patient care. Identify and differentiate the common clinical presentations of and Explain the causes of and Describe the indicated tests required to evaluate Discuss the treatment goals for patients hospitalized with such as and control Explain indications, contraindications, and mechanisms of action of pharmacologic agents used to treat cardiac Describe the role of in the treatment of cardiac using evidence-based risk stratification tools. Describe

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