PEDIATRIC INPATIENT CURRICULUM - AFMA



INPATIENT PEDIATRIC CURRICULUM & COMPETENCIES

FIRST YEAR RESIDENTS

A. Goal

To teach the diagnostic and management skills necessary to handle the common pediatric problems requiring hospitalization and the common newborn problems in the nursery that would be encountered by a family physician.

B. Faculty

1. Members of the Department of Pediatrics

2. Family Medicine Residency Faculty

3. Clinical Coordinator of Pediatrics (Dr. Russ Gombosi) and the Senior Associate Director of the Family

Medicine Residency Program (Dr. Verzella) are responsible for the educational objectives/curriculum

C. Format

1. Two one-block rotations on the Pediatric Inpatient Service (including newborn nursery), supervised by the second year resident on Pediatrics.

2. Patients to be cared for:

a. Inpatients and newborns of the Pediatric Service attending, consisting of his/her private patients and those without primary doctors. Supervision of these patients by the Pediatric Service attending.

b. Pediatric inpatients of the Family Medicine Residency (office and community FPs) to be supervised by the Family Medicine faculty.

c. Newborns of the Family Medicine Residency (office and community FPs), unless a “private patient” of a resident/faculty. Only when that primary provider is away or had not previously agreed to follow the baby would the Inpatient Peds team follow. These patients will be under supervision of the Family Medicine faculty. “Sick newborns” may be transferred to the Inpatient Peds team or Level II Nursery team.

d. Level II newborns under the supervision of the Pediatric Hospitalists as appropriate.

e. Other private attending (pediatricians and community family physicians) may request resident involvement in their inpatient and newborn cases. Supervision in these cases will be by those private physicians. It is strongly recommended that residents be involved in all Pediatric Medicine cases admitted to the floor or ICU.

3. Consultations are occasionally requested from surgeons or other attendings, these are to be done initially by the second year resident, however the first year resident may co-follow these cases.

D. Responsibilities

1. Pediatric Inpatient Floor – First Year Resident

a. Charting

1. Full H&P including pertinent prenatal/neonatal, developmental, and social history (except when second year resident does the admission alone, i.e. when the first year is in the Family Medicine Residency Center)

2. Admitting evaluation and orders

3. Dictated H&P within 24 hours (if first year performed admitting H&P)

4. Daily management plans, orders, progress notes (may be shared with second year resident if service is extremely busy)

5. Discharge planning/instructions

6. Dictated discharge summary within 72 hours (if first year performed the discharge)

All of the above will be discussed with the supervising second year resident and the appropriate attending physician.

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PEDIATRIC INPATIENT CURRICULUM & COMPETENCIES (PGY 1)

b. Rounds

1. Will be made daily with the Pediatric Service attending and with the Family Medicine Pediatric faculty (if there are pediatric Family Medicine patients)

2. Rounds on private pediatricians’ and the community family physicians’ patients will be discussed with those attendings at mutually agreeable times either by phone or in person.

3. Most attendings will round at some time after morning report

4. On Pediatric Service cases and Family Medicine Pediatric cases, residents should be allowed to write all initial orders and perform all initial diagnostic tests unless they are delayed/prevented from providing timely care due to other duties.

5. On private patients (pediatrician or community family physicians), orders may already come with the patient from that physician’s office. You should still develop your own set of orders for practice, not looking at the attending’s orders, then compare and contrast them. The attending will usually want their orders used, but you should discuss the differences when you go over the case with them.

2. Nursery

a. Admission and discharge exams on all appropriate newborns (see format section); send a copy of the Newborn Admit and Discharge Exam form to the primary provider.

b. Dictated discharge summaries within 72 hours on sick newborns with a copy to the primary provider (on those patients directly discharged by that resident)

c. Perform circumcisions under direct supervision of the second year resident and/or the pediatric attending, Family Medicine attending, or private attending

d. When available, attend all C-Sections and complicated deliveries in L&D for potential newborn resuscitation, with the exception of the following: elective uncomplicated vertex C-section with regional anesthesia (these will be covered by Respiratory Therapy) (see attached protocol).

e. Daily rounds with appropriate attending as outlined above.

3. Rounds on weekends will be split evenly between the first and second year residents such that each resident gets at least one day/week off (on the average).

4. The resident must attend morning report (except when rounding), noonday conference, and visiting professor lecture series. The Pediatric Cases will be presented on Tuesday at morning report.

5. Family Medicine Residency Center hours are Tuesday 1:30PM-5:00PM

6. Potential admissions in the Emergency Room will be evaluated by the first year resident in conjunction with the second year resident (if not in the Family Medicine Residency Center)

E. Schedule

| |MONDAY |TUESDAY |WEDNESDAY |THURSDAY |FRIDAY |

|AM |Rounds |Am Report |Rounds |Rounds |Visiting Professor |

| | |----------------------- | | |----------------------- |

| | |Rounds | | |Rounds |

|PM |Patient Care & Self-directed|Family Medicine Residency |Patient Care & Self-directed|Patient Care & Self-directed|Visiting Professor |

| |Learning |Center |Learning |Learning |----------------------- |

| | | | | |Patient Care & Self-directed|

| | | | | |Learning |

F. Competencies/Learning Objectives for Inpatient Pediatrics (PGY1)

1. Patient Care: Residents must be able to provide family centered patient care that is developmentally and age appropriate, compassionate, and cost effective for the treatment of health problems and the promotion of health.

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PEDIATRIC INPATIENT CURRICULUM & COMPETENCIES – PGY1

a. Communicate effectively and demonstrate caring and respect when interacting with children, adolescents, and their families.

b. Gather essential and accurate information about their patients from all available sources (parents, care givers, old records, etc) and perform the age and developmentally appropriate exam to develop a complete pediatric H+P or Newborn Care plan.

c. Make informed decisions about diagnostic and therapeutic interventions based upon patient information, current scientific evidence, and clinical judgment. Use of all pertinent lab/test/exam data to formulate an appropriate differential diagnosis upon which to make those decisions is key.

d. Develop and carry out patient care management plans based on the presenting problem and formulated differential diagnosis.

e. Counsel and educate patients and their families regarding the current care plan, anticipatory guidance upon discharge, and by providing comfort and allaying fear.

f. Use information technology to optimize patient care through Web-based and PDA based resources.

g. As medically indicated, competently perform appropriate diagnostic/therapeutic procedures, which may include (but not limited to): Lumbar Puncture, Bladder Catheterization, Suprapubic Aspiration, Circumcision with Dorsal Penile Block.

h. Address age appropriate Health Maintenance concerns at the time of admission and/or discharge.

i. Work with other members of the health care team to provide patient-focused care.

2. Medical Knowledge: Residents must demonstrate knowledge about established and evolving biomedical, clinical, epidemiological, and social-behavioral sciences and the application of this knowledge to patient care.

a. Demonstrate investigatory and analytic thinking by caring for patients who present with a variety of symptoms as well as diseases, from single system to complex, applying both basic and clinical science to each case as appropriate.

b. Demonstrate competency in managing the common pediatric inpatient conditions faced by a family physician in the community setting and determining when consultation is needed, to include (but not limited to):

1. Acute Abdominal Pain

2. Respiratory Emergencies (Apnea/ALTE, Asthma, Bronchiolitis, Croup, Pneumonia)

3. Failure to Thrive

4. Sepsis or possible sepsis

5. Fever without a source

6. Gastroenteritis and/or Dehydration

7. Hyperbilirubinemia

8. Urinary Tract Infection

9. Suspected Child Abuse

10. Normal Newborn Care in the Nursery

11. Prematurity

12. The “Sick” Neonate – Respiratory Distress, Congenital Heart Disease, Hypoglycemia, Sepsis risk, Meconium Aspiration, Dysplastic Hip

c. Successful completion of the Neonatal Resuscitation Provider and Renewal courses and

the S.T.A.B.L.E. course (when offered0

3. Practice-Based Learning and Improvement: Residents must be able to use scientific methods and evidence to investigate, evaluate, and improve their patient care practices.

a. In caring for patients, residents will utilize hospital based resources such as Web-based tools like UpToDate, MD consult, InfoPOEMS, as well as current text-based resources such as Pediatrics-In-Review to access the most current and evidence based approaches to patient care. This material will also be discussed on daily teaching rounds as well as during the weekly Pediatric Morning report.

b. Use handheld devices to provide optimal patient care “at the bedside”.

c. Take an active role in teaching Medical and other students rotating with the Inpatient Team

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PEDIATRIC INPATIENT CURRICULUM & COMPETENCIES - PGY 1

4. Interpersonal and Communication Skills: Residents must be able to demonstrate interpersonal and communication skills that result in effective information exchange and teaming with patients, their families, and professional associates.

a. Create and sustain therapeutic and ethically sound relationships with patients and their families

b. Meet daily with patients and families, using effective listening skills, discussion with appropriate verbal and non-verbal cues, avoiding “medicalese”.

c. Work effectively with other members of the health care team, including the ER staff, Specialists, Respiratory Therapists, Dieticians, and Social Workers.

d. Chart daily progress notes including status, diagnostic results, and ongoing plans.

e. Timely dictations of the Admitting H+P and Discharge Summary with feedback going to the primary provider.

5. Professionalism: Residents must demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to diversity.

a. Interact with the ethnically and socio-economically varied patient population that exists in Williamsport and the more rural surrounding areas.

b. Continue to develop compassionate, empathetic, and culturally sensitive communication with patients and their families, while also providing age and developmentally appropriate care.

c. Continually demonstrate appropriate ethical and professional behavior, including maintenance of patient confidentiality at all times.

6. Systems-Based Practice: Residents must practice quality health care and advocate for patients in the health care system

a. Provide high quality but cost effective health care via collaboration with Case Managers, Social Workers, and the Home Health Services as applicable to each patient.

b. Use PDA and Text based formularies to help provide the most cost effective medicines for families

c. Adhere to the legal mandate in the State of PA to report any suspicions of Child abuse or neglect to Children and Youth and the Child Abuse Hotline.

d. Follow SHS patient care protocols such as for Babies of GBS+ Mothers or Babies at Risk for Infection, as well as AAP consensus guidelines such as Hyperbilirubinemia or Hip Dysplasia to optimize patient care.

G. Resources

1. Nelson’s Textbook of Pediatrics

2. Manual of Pediatric Therapeutics

3. Manual of Neonatal Care

4. 5 Minute Pediatric Consult

5. American Academy of Pediatrics “Redbook”

6. Pediatrics in Review

7. Other PDA and web-based resources as needed

H. Evaluation Methods

1. Direct observation

2. 360° evaluation tool by nurses and families

3. Competency-based rotation evaluation by attendings

4. Supervising resident peer evaluation

5. Pediatric Topic Checklist

Revised 11/2014 JV

NEONATAL RESUSCITATION CURRICULUM

(First Year)

A. The following protocol has been established to help ensure adequate experience in neonatal resuscitation so that residents feel comfortable and competent in the resuscitation and stabilization of distressed newborns by the time they complete their training in the Residency. This training will include attaining appropriate knowledge and skills in neonatal life support and the correct performance of the following:

1. Initiation of bag-mask ventilation

2. Use of free flow oxygen

3. Visualization of the vocal cords with subsequent intubation

4. Suction of meconium via the ET tube

5. Endotracheal intubation and assisted ventilation

B. Procedure

1. First year residents will successfully complete the Neonatal Life Support Course (NLS), as soon as available in their training in order to correctly learn the principles and practice of newborn resuscitation

2. The first or second year resident on the Pediatric Rotation will attend all C-Sections outlined in the Pediatric Training Format and attached protocol and vaginal deliveries complicated by fetal distress or meconium staining, and perform the appropriate neonatal resuscitation needed under the supervision of the pediatrician in attendance (or family physician if supervising attending). Both residents may attend if available and desired.

3. Documentation of experience should be done in New Innovations for all resuscitations attended or performed.

4. Any resident who has still not achieved competence in newborn resuscitation by the end of the second year will need an individualized education plan, to be carried out in his/her third year, which will offer the opportunity to acquire the appropriate skills.

Revised 11/2014 JV

CIRCUMCISION PRIVILEGES

A. Residents will be granted unsupervised circumcision privileges via:

1. If a resident wants them immediately after completing the 2nd Peds rotation, he/she must submit a request to his/her Faculty Advisor, who will review the procedure numbers.

2. If a resident wants them prior to completing the 2nd Peds rotation (i.e. sometime after finishing the 1st), he/she must do at least one with the FM faculty before submitting his/her request to the Faculty Advisor.

3. The Faculty Advisor will recommend the resident to the Department Chairman (currently Dr. Ambrose) for privileges, who will in turn submit his recommendation to the Medical Director (Dr. Manchester).

4. If a resident does NOT request circumcision privileges by the end of the first year, Dr. Ambrose will automatically request privileges from Dr. Manchester at the start of 2nd year, so that proper supervision of the incoming new first year residents can be done. NOTE: if a resident waits to do this it could delay his/her actually getting privileges until 2-3 months into 2nd year.

B. Residents will be granted unsupervised dorsal penile block privileges via:

1. Requesting them after at least 3 have been successfully performed, with at least 1 being supervised by the FP Faculty or Pediatricians, (the others can be by residents with privileges). Again, the request goes to the Faculty Advisor.

2. If a resident does NOT request dorsal block privileges by the end of 1st year, Dr. Ambrose will automatically request them from Dr. Manchester at the start of 2nd year, providing adequate numbers/technique had been attained.

Revised 5/2010 JV

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