Inpatient Child Neurology

Inpatient core clinical training in Child Neurology

PEDIATRIC NEUROLOGY ROTATION WARDS AND CONSULTS

Introduction

One of the primary clinical responsibilities of a practicing child neurologist is to serve as a consultant for patients with a variety of neurological problems in the hospital setting. Consults may be requested for primary neurological diseases, neurological complications of systemic diseases, or the neurological complications associated with medical and surgical therapies. Patients seen in consultation are in the emergency department, pediatric or neonatal ICU, or general medical floor.

This is the primary inpatient experience during child neurology training.  The inpatient consult team is led by the child neurology resident and also includes the pediatric neurology attending, a junior adult neurology resident, a nurse practitioner, and medical students.  The child neurology resident will be in charge of the pediatric neurology consult service thereby seeing new patients and follow-up existing consult patients. Early in PGY4 the child neurology resident functions as a junior resident.  Responsibility of the PGY4 changes over the course of the year, evolving from a junior resident role to a senior role, based on faculty evaluations and resident readiness.  Adult neurology residents will rotate on the service who the child neurology resident will supervise.  While in a senior role, the child neurology resident is expected to be familiar with all of the patients on service, even those who are primarily being followed by the junior neurology resident.

Schedule

Early in the PGY4 year the child neurology resident is assigned to the pediatric neurology consult pager each weekday from 8:00 am to 4:00 pm.  When the PGY4 responsibility shifts from junior to senior, the adult neurology junior resident will then be assigned to the pediatric neurology consult pager.  Attending teaching rounds will occur daily usually starting between 9:00-9:30 am. At 4:00 pm, the night float resident will become first call on the pager. The residents on the pediatric neurology consult team will then finish seeing and staffing any consults that were received before 4:00 pm and give formal sign-out on active consult patients (if any) to the night float resident.

The child neurology resident is expected to attend regularly scheduled educational lectures unless addressing urgent or emergent clinical issues for service patients.

Patient Care

Goals

1. Gather essential and accurate information necessary to provide comprehensive care to pediatric patients with neurological disorders.
2. Demonstrate effective and appropriate clinical problem solving skills using evidence-based medical knowledge and sound clinical judgment.
3. Recognize the ethical, personal and social implications of many neurological diagnoses as well as the issues surrounding predictive testing and interventions for individuals with severe disabilities and their families.
4. Provide care to pediatric patients of varying ages and develop skills necessary to provide longitudinal care throughout the lifespan.
5. Develop competence at inpatient and intensive-care management for a variety of pediatric neurological conditions. In addition, the resident will respond to consultation requests from the UW-ER and develop skills at triaging patients to the general or one of subspecialty services.
6. The residents will increase their knowledge of the pathophysiology of common neurologic conditions in hospitalized children and will understand how to diagnose and treat these conditions. Additionally, they will be comfortable providing family-centered care in an interdisciplinary setting.

Objectives

Residents will:

1. Develop basic competence in the medical care of children with neurologic disease, and will begin to work on finer points such as improving patient safety, cost-effectiveness of care, and transitioning the patient to outpatient care.
2. Supervise the junior neurology residents and medical students and both create and direct the care plan for the patient (under the guidance of the supervisory faculty member).
3. Learn how to relate radiology results to the clinical diagnosis and proper management of patients with all manner of neurologic disease.
4. Describe and explain the etiology, symptoms, pathophysiology, treatment options (with risks and benefits) and prognoses of common neurological diseases in childhood and their differential diagnosis.
5. Acquire competency in performing physical examinations of infants and children.
6. Learn to recognize abnormal patterns of neurodevelopment.
7. Learn to interpret neuro-diagnostic studies in infants and children.
8. Learn to diagnose and manage neurological emergencies in children.
9. Develop effective interactions with consulting services and ancillary staff.
10. Acquire effective practice management skills.
11. Learn to take a personal initiative in self-education (including pursuing recent literature) and demonstrate an investigatory and analytic thinking approach to clinical situations. This encompasses reading textbooks as well as review of recent scientific literature.
12. Gather and document essential and accurate information in medical interviews, including relevant illness, past medical, family, social, diet, and developmental history.
13. Perform and document complete physical and neurologic examinations in children of all ages, including developmental assessments.
14. Develop thoughtful and appropriate assessments and plans of care utilizing the principles of evidenced-based decision making and problem solving.
15. Facilitate timely evaluation and management of care plans.
16. Provide vigilant and appropriate monitoring of the clinical and neurologic status of hospitalized patients including:

1. 1. Appropriate use of non-invasive monitoring (continuous video EEG).
   2. Careful data collection and synthesis.
   3. Frequent neurologic exam assessment.
   4. Responsiveness to patient, parent, and nursing concerns.
   5. Appropriate nutrition, activity and medication orders.
   6. Prompt identification of and response to changes in patient condition and critically ill   patients.

17. Order and interpret labs and studies commonly used in inpatient pediatric neurology patients, taking into account age-related normal values.
18. Use the electronic medical record to facilitate optimal patient care by:

1. 1. Updating permanent parts of the medical record (including problem lists).
   2. Writing timely daily notes that convey the thought process involved in patient management decisions and can be easily interpreted by those reading the medical record.
   3. Ensuring that the medical record reflects the current situation for each patient (creating addendums to the daily note and entering event notes)

19. Effectively counsel patients and families by:

1. 1. Sharing information about illness and treatment.
   2. Encouraging involvement in patient care and clinical decisions.
   3. Preparing patients and families for discharge.
   4. Utilizing educational resources for patients and families.

20. Facilitate smooth transitions of patient care

1. 1. Obtain information from and communicate with referring providers.
   2. Discuss management and hospital course with primary care provider.
   3. Provide thorough and appropriate sign-out to covering residents.
   4. Ensure continuity for in-hospital transfers (communicate with other providers/services both verbally and in writing).

21. Facilitate appropriate discharge planning (orders and medication reconciliation, patient education including specific and meaningful verbal and written discharge instructions, scheduled follow-up appointments).

Medical Knowledge

Goals

1. Develop self-directed learning skills essential to the maintenance of expertise in Child Neurology.
2. Use internet and printed resources including primary and secondary literature, relevant texts and published databases to acquire, critically evaluate, and use current knowledge regarding diagnostic test availability and applicability, natural history, and management of each disorder with which inpatients and clinic patients are diagnosed.
3. The resident will develop an adequate knowledge base in Child Neurology and the neurosciences.
4. The resident will continue to learn how the health care system functions, especially as relevant to the pediatric patient with neurologic disease.

Objectives

Residents will:

1. Develop competence in basic neurologic knowledge and will begin to attain a sophisticated and deep knowledge base in child neurology and the neurosciences.
2. Describe and explain the etiology, symptoms, pathophysiology, treatment options (with risks and benefits) and prognoses of common neurological diseases in childhood and their differential diagnosis.
3. Acquire competency in performing physical examinations of infants and children.
4. Learn to recognize abnormal patterns of neurodevelopment.
5. Learn to interpret neuro-diagnostic studies in infants and children.
6. Learn to diagnose and manage neurological emergencies in children.
7. Develop effective interactions with consulting services and ancillary staff.
8. Acquire effective practice management skills.
9. Learn to take a personal initiative in self-education (including pursuing recent literature) and demonstrate an investigatory and analytic thinking approach to clinical situations. This encompasses reading textbooks as well as review of recent scientific literature.

Interpersonal and communication skills

Goals

1. Demonstrate interpersonal and communication skills that result in information exchange and partnering with patients, their families and professional associates.
2. Residents will become skillful listeners, and develop specific proficiency in communicating with pediatric neurologic patients through non-verbal means and with their care providers.
3. Residents will learn to communicate rapidly and efficiently with other team members in order to ensure that proper therapies can be provided in a timely manner.
4. Residents will learn to clearly communicate neurological assessments and plans to patients and their parents, and members of the multidisciplinary care team.

Objectives

Residents will:

1. Continue to master skill at interpersonal communication and will not only demonstrate professional and ethical practice of medicine, but help more junior residents to foster their professionalism.
2. Supervise the junior neurology residents and medical students and both create and direct the care plan for the patient (under the guidance of the supervisory faculty member).
3. Master teaching skills.
4. Effectively communicate in a timely manner with fellow residents, medical students, attending physicians, consulting and transferring services, primary care providers, nurses, ancillary staff members, patients and families.
5. Facilitate safe and efficient patient care via complete but concise presentations (on rounds, when discussing care with consultants, when signing out to co-residents).
6. Appropriately utilize the electronic medical record as a communication tool.
7. Collaborate with case management and nursing to ensure efficient and appropriate discharge plans.
8. Provide effective education, including reassurance, for conditions commonly seen on the inpatient service.
9. Effectively interact with children in a manner that is appropriate for their age/developmental level and promotes comfort and understanding.
10. Communicate with parents/caregivers/families by establishing rapport, inspiring confidence and trust and keeping them informed and involved in clinical care decisions.
11. Demonstrate sensitivity to and respect for patients and families beliefs, religion, ethnicity, and cultural values.
12. Ensure continuity of care by communicating effectively with primary care providers both verbally and through timely, appropriately detailed written discharge summaries.
13. Accept and provide feedback willingly.

Professionalism

Goals

1. Demonstrate continuing commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to diversity.
2. Learn ethical, regulatory, and legal aspects of pediatric neurologic care, including the difference between standard and investigational treatments.
3. Demonstrate sensitivity to the personal, cultural, and religious values that influence patients’ and parents’/caregivers’ medical decisions in the context of neurologic disease.
4. Demonstrate responsiveness to patient needs that supersedes self-interest.
5. Demonstrate compassion, integrity, accountability and respect in all interactions with patients from diverse backgrounds in gender, age, culture, race, religion, physical and cognitive ability and sexual orientation.
6. Adhere to ethical principles by respecting confidentiality of medical information

Objectives

Residents will:

1. Place patient needs paramount; always act in the best interest of the patient.
2. Demonstrate personal accountability for the wellbeing of patients (following up lab results, writing comprehensive notes, seeking answers to patient care questions).
3. Work collaboratively and cooperatively as a member of a health care team, demonstrating a commitment to professional behavior in interactions with staff and professional colleagues.
4. Demonstrate reliability, responsibility, and respect for patients and families, including appropriate verbal and nonverbal communication.
5. Arrive on time for scheduled activities and appointments.
6. Demonstrate a commitment to professional responsibilities, even during periods of stress, by:
   1. making a personal commitment to a respectful workplace;
   2. working collaboratively with other members of the health care team;
   3. engaging in self-assessment; and
   4. accepting external scrutiny to maintain professional standards.
7. Adhere to ethical and legal principles.

Practice-Based Learning and Improvement

Goals

1. Demonstrate knowledge, skills and attitudes needed for continuous self-assessment, using scientific methods and evidence to investigate, evaluate, and improve one’s patient care practice.
2. Identify opportunities for improvement

Objectives

            Residents will:

1. Regularly utilize the available medical literature to make evidence-based decisions in patient care by:
   1. Formulating pertinent clinical questions.
   2. Retrieving and critically appraising relevant up-to-date information.
   3. Applying that information to inform clinical decisions.

1. Observe and provide feedback to students and junior residents about history and exam skills, discussing cases seen together, and writing orders together.
2. Identify personal learning needs, systemically organize relevant information resources for future reference and plan for continuing acquisition of knowledge and skills.
3. Incorporate evaluation feedback into daily practice.
4. Read, analyze and critique journal articles.
5. Systematically review clinical outcomes in order to contribute to the body of knowledge in pediatric neurology.

Systems-Based Practice

Goals

Understand how to practice high quality health care and advocate for patients within the context of the health care system.

Objectives

Residents will:

1. Learn how he/she can best utilize the health care system for the welfare of his/her pediatric patients with acute and chronic neurologic conditions.
2. Identify key aspects of health care systems, cost control, billing, and reimbursement in the inpatient setting.
3. Demonstrate sensitivity to the cost of providing inpatient care and resource allocation, take steps to minimize costs without compromising quality of care.
4. Take steps to avoid medical errors by recognizing the limits of one’s knowledge and expertise; work with the health care team to recognize and address systems errors.
5. Understand the value of appropriate use of laboratory and radiographic testing, as well as their limitations.