Core Competencies – Society for Pediatric Urgent Care

The following competencies for fellowships in pediatric urgent care were developed by members of the Education Committee of the American Academy of Pediatrics (AAP) Section on Urgent Care Medicine (SOUCM), with the aim of establishing consistent clinical training goals across current and developing fellowship programs.

Pediatric Urgent Care Fellowship Core Competencies

The fellowship in pediatric urgent care medicine is a one-year fellowship designed to provide additional clinical, academic, administrative, and teaching experience for a general pediatrician who desires to provide high-quality patient care in the urgent care or emergency department setting. In addition to the requirements for general pediatrics board certification set forth by the American Board of Pediatrics, fellows will be expected to meet the core competencies of Patient Care, Medical Knowledge, Practice-Based Learning and Improvement, Interpersonal and Communication Skills, Professionalism, and Systems-Based Practice, as related to the field of pediatric urgent care medicine.

Patient Care

Fellows will acquire the cognitive and technical skills for the compassionate care of the acutely ill or injured child, as well as the ability to recognize when the care the patient requires exceeds the abilities of the provider or the site in which he/she practices, and to stabilize the patient prior to transfer to a higher level of care.

The fellow will:

Gather accurate information from all sources, including interviews with the patient/family, medical records, problem-focused physical exam, and diagnostic and therapeutic procedures
Learn to skillfully obtain a history and physical exam while being thorough yet problem-focused
Formulate a diagnostic and therapeutic plan
Learn to competently implement diagnostic and therapeutic plans
Understand who needs emergent or urgent transfer to an emergency department, hospital, or higher level of care
Develop the ability to multitask by managing multiple patients, while being able to prioritize by acuity
Develop and demonstrate competence in procedural skills that are commonly performed in the urgent care setting
- Basic/advanced suturing (see Medical Knowledge/Wound Management for details)
- FB removal – Ear, Eye, Nose, Soft tissue
- Abscess I&D
- Fluorescein exam, ocular irrigation/decontamination
- Nerve blocks
- Splinting
- Simple joint reductions – shoulder, patella, finger/toe, radial head subluxation
- Procedural Sedation
- Tick removal
Formulate appropriate disposition and follow-up for all patients
Communicate with community physicians in order to provide continuity of care
Understand the role of consultants in the urgent care setting, and when it’s appropriate to use them
Demonstrate competence in addressing patient pain and comfort in the ED/UC setting, including appropriate sedation for short procedures as deemed appropriate by credentialing
Maintain PALS certification, and demonstrate the ability to stabilize and transfer critically ill patients in the outpatient setting
Demonstrate appropriate resource utilization (lab, radiology, consults, etc), and practice cost-effective care

Medical Knowledge
Overview – The fellow will learn to evaluate a comprehensive array of signs and symptoms, as outlined in Appendix 1. The fellow will be expected to diagnose and treat the broad scope of illness and injury that presents to the pediatric urgent care setting.

The fellow will be expected to:

Demonstrate knowledge of established and evolving biomedical, clinical, epidemiological and social-behavioral science, as well as the application of this knowledge to patient care. Fellows must demonstrate knowledge of the clinical and basic sciences as related to pediatric urgent care.
Apply an analytical approach to acquiring new knowledge, access and critically evaluate current medical information and scientific evidence, and apply this knowledge to clinical decision-making
Gain an understanding of the depth and breadth of ill and injured patients that can present to an urgent care setting
Learn who can be safely and effectively managed in an urgent care setting
Learn the differential diagnosis of presenting problems within the scope of urgent care practice
Gain knowledge of the clinical features, diagnostic criteria, epidemiology, natural history, pathophysiology, complications and consequences of both common and rare illnesses and injuries
Learn through observation, supervision, then independent performance, the various indications and methodology of diagnostic and therapeutic procedures common to pediatric urgent care medicine
Increase knowledge in the interpretation of diagnostic radiology, especially radiographs of common fractures seen in the pediatric urgent care setting
Understand some of the basic legal issues encountered in the pediatric urgent care setting

Medical Knowledge Specific to Urgent Care (Organized by Specialty)

The fellow should be able to recognize and manage the following pathologies. For emergent or critical illness, the fellow is expected to recognize, stabilize, and initiate management and transfer as appropriate. Critical illness will be noted with an “(C)”.

Allergy
- Allergic reactions
- Allergic rhinitis/conjunctivitis
- Angioedema (C)
- Anaphylaxis / Anaphylactic shock (C)
- Serum sickness

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Cardiac/Cardiothoracic disorders
- Pericardial effusion / Pericardial disease
- Pleural effusion
- Hypertension
- PALS techniques to manage cardiac and cardiopulmonary arrest (C)
- Complications of congenital heart disease
- Congestive heart failure
- Cardiogenic shock (C)
- Cardiac tamponade (C)
- Arrhythmias (C)
- Myocarditis
- Endocarditis
- Deep Vein Thrombosis

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Child abuse
- Non-accidental trauma
  - Recognize physical exam findings and radiographic patterns of abuse
- Sexual abuse, including sex trafficking
- Emotional abuse
- Neglect
- Munchausen Syndrome by Proxy

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Dermatologic disorders
- Recognition, stabilization, and initial management of dermatologic manifestations of critical illness:
  - Measles
  - Meningococcemia (C)
  - Necrotizing fasciitis (C)
  - Toxic Shock Syndrome (C)
  - Staph Scalded Skin Syndrome (C)
  - Rocky Mountain Spotted Fever
  - Toxic Epidermal Necrolysis (C)
  - Erythema Multiforme Minor
  - Erythema Multiforme Major / Steven’s Johnson Syndrome (C)
- Herpes Zoster
- Eczema Herpeticum
- Disseminated Gonococcal Infection
- Varicella
- Atopic dermatitis
- Seborrheic dermatitis
- Diaper dermatitis
- Contact dermatitis
  - Rhus dermatitis
- Bites and infestations
- Urticaria
- Fungal infections of the skin
- Pityriasis rosea
- Warts/plantar warts
- Molluscum contagiosum
- Herpes simplex virus, acquired/congenital
- Localized Bacterial Infections of the skin (cellulitis, impetigo, ecthyma, abscess)
- Pyogenic granuloma
- Panniculitis

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Endocrine
- Diabetic ketoacidosis (C)
- Acute adrenal insufficiency
- Diabetes insipidus
- SIADH
- Hyper/hypo-glycemia
- Hyper/hypo-calcemia
- Hyper/hypo-thyroidism

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ENT
- Otitis media
- Mastoiditis
- Otitis externa
- Allergic and infectious rhinosinusitis
- Pharyngitis / tonsillitis
- Peritonsillar abscess / cellulitis
- Retropharyngeal abscess (C)
- Facial cellulitis
- Angioedema
- Parotitis
- Epistaxis
Foreign body diagnosis and management:
- Nose
- Ear
- Esophagus
Oral infections, including dental abscess, gingivostomatitis
ENT/Facial Trauma (see Trauma for details)

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Environmental exposures
- Animal, insect, spiders, reptile and human bites/stings
- Burns
- Carbon Monoxide exposure (C)
- Inhalation Injury (C)
- Drowning (C)
- Frostbite
- Heat exhaustion and Heat Stroke (C)
- Hypothermia (C)
- Electrical injuries
- Altitude sickness (HAPE/HACE)
- Decompression illness

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Gastrointestinal disorders
- Acute gastritis, enteritis, gastroenteritis
- Dehydration, oral rehydration, use of ondansetron
- Foreign Body ingestion
- Gastroesophageal reflux
- Hepatitis
- Pancreatitis
- Gallbladder disease (Cholecystitis, Cholangitis, Choledochololithiasis)
- Inflammatory bowel disease
- Intussusception
- Malrotation with volvulus (C)
- Pyloric stenosis
- Appendicitis
- Inguinal hernia
- Intestinal obstruction
- Hirschprung’s disease
- Upper GI Bleed
- Lower GI Bleed

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Gynecologic problems
- Pregnancy, Ectopic pregnancy (C), and early pregnancy complications (e.g. spontaneous abortion)
- Abnormal uterine bleeding
- Dysmenorrhea
- Labial adhesions
- Congenital vaginal obstruction (imperforate hymen, transverse vaginal septum)
- Bartholin’s gland cyst/abscess
- Ovarian torsion (C)
- Ovarian cysts (+/- rupture)
- Nonspecific vaginitis

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Hematologic/Oncologic disorders
- Complications of sickle cell hemoglobinopathies (fever, pain crises)
- Neutropenia
- Thrombocytopenia ( Idiopathic Thrombocytopenic Purpura and other causes)
- Coagulopathies
- Fever and neutropenia (C)
- Tumor lysis syndrome (C)
- Hyperleukocytosis
- Mediastinal mass
- Anemia
- Typhlitis

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Infectious diseases
- Encephalitis (C)
- Localized and Disseminated Herpes infection, including Neonatal (C)
- Lymphadenitis
- Measles
- Meningitis (C)
- Mononucleosis
- Osteomyelitis
- Respiratory infections: pneumonia, bronchiolitis, pertussis, tuberculosis, influenza
- Sepsis (C)
- Sexually Transmitted Infections: Urethritis/Cervicitis, Pelvic Inflammatory Disease, Syphilis, Chlamydia, Gonorrhea, Herpes genitalis, HIV
- Septic arthritis (C)
- SSTI – Cellulitis, Abscess, Ecthyma, Impetigo, Fasciitis, Omphalitis, Mastitis
- Tick-borne illness: Rocky Mountain Spotted Fever, Lyme disease, Ehrlichiosis, etc.
- Urinary tract infection / pyelonephritis
- Varicella
- Viral exanthems – Measles, Rubella, Roseola, Erythema infectiosum

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Neonatal illness
- BRUE (Brief Resolved Unexplained Event)
- Failure to thrive
- Jaundice
- Inborn errors of metabolism (C)
- Fever/sepsis (C)
- NEC (C)

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Neurologic
- Tension, Migraine, Cluster Headache
- Transverse myelitis
- Botulism
- Myasthenia gravis
- Acute Disseminated Encephalomyelitis
- Acute cerebellar ataxia
- Facial nerve palsy/Bell’s palsy
- Seizures / Status epilepticus (C)
- Increased intracranial pressure (C)
  - VP Shunt complications
  - Pseudotumor cerebri
  - Obstructive/communicating hydrocephalus
  - Brain Tumor
- Stroke (C)
- Spinal Cord Compression (C)
- Guillan Barre Syndrome (C)
- Dystonia/Dystonic reaction

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Ophthalmology
- Corneal Abrasion
- Iritis
- Uveitis
- Herpes simplex keratitis
- Conjunctivitis
- Adnexal disease (stye, blepharitis, dacrocystitis)
- Foreign bodies
- Subconjunctival hemorrhage
- Chemical burn of the eye
- Preseptal cellulitis
- Orbital cellulitis
- Hordeolum
- Chalazion
- Optic neuritis

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Orthopedics
- Comprehensive musculoskeletal exams of the knee, hip, shoulder, elbow, forearm, wrist and back
- Recognize injury-related neurovascular compromise / compartment syndrome
- Recognize injuries requiring emergent orthopedic referral
- Recognize when radiographic evaluation is needed
- Diagnosis and management of ligamentous/tendon injuries
- Salter Harris classification of pediatric fractures
- Diagnosis (including X-ray interpretation) and management of specific fractures:
  - Clavicle
  - Proximal humerus
  - Supracondylar, lateral, and medial condyle fractures
  - Olecranon
  - Ulnar shaft
  - Radial head
  - Monteggia
  - Galeazzi
  - Midshaft and Distal radius and ulnar
  - Navicular/scaphoid
  - Metacarpals
  - Phalanges
  - Femur
  - Hip/Pelvis
  - Tibial fractures, including Toddler’s fracture
  - Fibular
  - Calcaneus
  - Metatarsal / Jones
  - Patellar
  - Avulsion fractures
  - Avascular necrosis of femoral head
  - Slipped Capital Femoral Epiphysis
  - Open Fractures
  - Vertebral
  - Rib
- Diagnosis and Management of Upper Extremity Soft Tissue Injuries:
  - Phalangeal dislocations
  - Mallet Finger and Trigger Finger
  - Ganglion Cyst
  - Felon and Paronychia
  - Carpal Tunnel Syndrome
  - Fingertip Amputation and Nailbed Injuries
- Diagnosis and Management of Lower Extremity Soft Tissue Injuries
  - Ligamentous Injuries of the Knee and Ankle
  - Achilles Tendon Injuries
  - Plantar Fasciitis, Sever’s, and other causes of Heel Pain
- Diagnosis and Management of Specific Dislocations:
  - Shoulder dislocation
  - Elbow dislocation
  - Subluxation of the radial head
  - Metacarpophalangeal dislocation
  - Interphalangeal dislocation
  - Knee dislocation
  - Patellar dislocation
- Lower back injuries (back strain, herniated disc, spondylolisthesis, etc)
- Atraumatic arthritis (toxic synovitis, septic arthritis, lyme arthritis, etc)

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Pain Management
- Techniques of distraction and other non-medicinal approaches to pediatric pain
- Evidence-based approach to pain management in urgent care setting
- Pharmacologic anxiolysis in our setting (midazolam)
- Approach to wound anesthesia, including topical anesthetics, nerve blocks, local infiltration

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Psychologic / Psychosocial
- Suicidal ideation
- Homicidal ideation
- Depression
- Anxiety/panic attacks/hyperventilation
- Eating disorders
- Substance abuse
- Sexual assault
- Management of the runaway adolescent/young adult

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Pulmonary
- Airway obstruction, upper and lower (C)
- Airway Foreign Body / Aspiration
- Pulmonary embolism
- Asthma / Status Asthmaticus (C)
- Croup
- Chronic Lung Disease of Prematurity
- Cystic fibrosis and its complications
- Pneumothorax, pneumomediastinum
- Pleuritis
- Respiratory distress/failure (C)

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Radiology
- Systematic interpretation of skeletal, chest and abdominal plain films.
- Common pediatric x-ray findings in the following conditions:
  - Gastrointestinal:
    - intestinal obstruction
    - perforation / free air
    - foreign body ingestion
    - intussusception
    - constipation
  - Upper Airway
    - croup
    - epiglottitis
    - retropharyngeal abscess
    - foreign body aspiration
  - Lower Airway / Chest
    - pneumonia
    - bronchiolitis
    - asthma
    - neoplasm
    - pneumothorax
    - pneumomediastinum
    - pleural effusion
    - pericardial effusion
    - CHF
  - Recognize injuries and diseases that require further imaging not commonly found in the urgent care setting (CT, Ultrasound, MRI, Fluoroscopy, etc)

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Renal
- Urolithiasis
- Nephrotic syndrome
- Acute glomerulonephritis
- Hyper and hypo-natremia, kalemia, calcemia
- Myoglobinuria / rhabdomyolysis
- Hemolytic-uremic syndrome
- Hypertension

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Resuscitation (All below terms require critical care skills)
- Demonstrate competence in BLS / PALS algorithms and management
  - Respiratory Failure
  - Recognize and stabilize major etiologies of shock
    - cardiogenic, hypovolemic, neurogenic and distributive shock
  - Be able to recognize and stabilize compensated and uncompensated shock
  - Know placement techniques and locations for intraosseus needle procedure
  - Cardiopulmonary arrest
    - Know the routes and indications for drugs used in resuscitation
      - Atropine
      - Calcium
      - Bicarbonate
      - Glucose
      - Epinephrine
      - Amiodarone
      - Adenosine
      - Lidocaine
    - Neonatal resuscitation

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Rheumatologic/Immunologic
- Juvenile Rheumatoid Arthritis
- Systemic Lupus Erythematosus
- Juvenile Dermatomyositis
- Henoch-Schonlein Purpura
- Typical/Atypical Kawasaki Disease
- Rheumatic fever

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Toxicology
- Principles of prevention of absorption, enhancement of elimination
- Knowledge of common toxidromes
- Recognition of withdrawal symptoms
- Urgent care approach to the intoxicated patient, including stabilization, consultation of poison control and indications for transfer
- Be able to recognize and manage the following specific ingestions, management, and antidotes/reversal if applicable:
  - Acetaminophen
  - Anticholinergics (diphenhydramine, etc)
  - Aspirin
  - Beta-blockers
  - Calcium channel blockers
  - Carbon monoxide
  - Caustic ingestion
  - Common household items (like detergent pods)
  - Cocaine/amphetamine
  - Cyanide
  - Ecstasy/MDMA
  - Hydrocarbon ingestion
  - Iron
  - Lead
  - Marijuana/ synthetic cannabinoids
  - Narcotics/sedatives/hypnotics
  - Oral hypoglycemics
  - Opiates
  - Organophosphates
  - Tricyclic antidepressants
  - Toxic Alcohols
- Environmental toxicology
  - Plant
  - Envenomations

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Trauma
- Recognize mechanisms and patterns of injury that may require higher level of care (e.g. MVA, suspected major organ injury, abnormal mental status / vital signs)
- Primary and secondary survey
- Neurologic trauma
  - Concussion and minor head injury
  - Intracranial hemorrhage (C)
  - Spinal cord injury (C)
  - Skull fracture
  - C-spine injuries, indications for immobilization, imaging, and management, including SCIWORA (C)
- Facial trauma (Eye, Ear, Face)
  - Facial bone fractures, including orbital fracture, mandible fracture
  - Penetrating Trauma / Ruptured globe (C)
  - Hyphema
  - Conjunctival, corneal foreign bodies, corneal abrasion
  - Traumatic iritis
  - Management of lip and oral laceration, including the tongue, gingiva, frenulum
  - Dental trauma: Know which injuries require emergent/urgent/routine dental follow-up
  - Nasal bone injury
  - Nasal septal hematoma
  - Auricular hematoma
- Thoracic trauma (all below pathologies require critical care skills)
  - Be able to recognize life threatening conditions that require immediate transfer; be able to institute therapy while awaiting transfer for:
    - Flail chest
    - Pneumothorax (Simple/Tension)
    - Great vessel injury
    - Pericardial tamponade
    - Hemothorax
    - Sucking chest wounds
    - Tracheobronchial rupture
    - Diaphragm injury
    - Cardiac trauma
    - Pulmonary contusion
    - Penetrating thoracic trauma
  - Abdominal trauma (all below pathologies may require critical care skills)
    - Recognize limits of physical exam, laboratory evaluation and radiologic assessment of abdominal and retroperitoneal injuries in children
    - Recognize concerning patterns of abdominal injury
      - Handlebar-related injuries
      - Chance fractures (risk of bowel injury)
      - Seat Belt Sign
    - Recognize mechanism and presentation of abdominal injuries that require immediate transfer for further evaluation and management
      - Liver Laceration
      - Splenic Laceration
      - Pancreatic injury
      - Duodenal hematoma
      - Bowel Injury
      - Penetrating abdominal trauma
    - Recognize need for resuscitation/stabilization while awaiting transfer
  - Genitourinary trauma
    - Recognize signs and symptoms, and need for transfer, of urethral trauma, bladder trauma, renal and pelvic injury
    - Understand role of urinalysis in management of child with flank trauma
    - Straddle injury
  - Musculoskeletal trauma – Please see Orthopedics section

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Urologic illnesses
- Phimosis
- Paraphimosis
- Balanitis
- Balano-posthitis
- Testicular torsion (C)
- Epididymitis/orchitis
- Urethral prolapse
- Priapism
- Zipper entrapment

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Wound Management
- Importance of wound exploration for suspected foreign body, tendon injury, neurovascular compromise
- Indications for primary, secondary, and delayed primary closure of wounds
- Role of irrigation and debridement in wound management
- Patterns and sites of wounds requiring cosmetic plastics consultation
- Advantages, disadvantages and contraindications of different types of suture material
- Complications of puncture wounds
- Management of nailbed injuries, paronychia, ingrown toenail
- Incision, drainage of abscess, +/- packing
- Indications for wound prophylaxis with antibiotics
- Indications for tetanus prophylaxis and immunoglobulin
- Indication/contraindications for types of wound closure
  - Tissue adhesive
  - Staples
  - Sutures
  - Hair Apposition Technique (HAT)
  - Wound taping
- Basic Repair Techniques:
  - Simple Interrupted
  - Vertical Mattress
  - Horizontal Mattress
  - Deep Closure
  - Corner Stitch
  - Partial Avulsion, Flap Wounds, Wounds with completely non-viable flap
  - Thin edge/Thick edge Laceration
  - Scalp laceration repair

C: Approach to common presentation of illness: The fellow should be able to formulate a differential diagnosis by age and plan for evaluation of the following signs and symptoms:

Abdominal pain/distention
Altered mental status
Back pain
Breast mass/swelling
Chest pain
Cough (acute and chronic)
Diarrhea
Dizziness / Vertigo
Dysphagia
Dysuria
Epistaxis
Fever
Fever in the international traveler
Fussy infant
Headache
Hematemesis
Hematochezia
Hematuria
Joint pain/swelling
Limp
Neck mass
Neck pain / stiffness
Otalgia / ear drainage
Pallor
Palpitations
Petechial rash
Red eye / eye discharge
Scrotal pain / swelling
Shortness of breath/respiratory distress
Stridor
Syncope
Tachycardia
Toothache
Vaginal/urethral discharge
Vaginal bleeding
Impaired visual acuity
Vomiting
Weakness
Wheezing
Weight loss

III. Interpersonal and Communication Skills

Fellows are expected to exhibit communication and interpersonal skills that result in effective information exchange and a collegial environment. This includes:

Demonstrate appropriate, clear communication with patients during clinical encounters and through written instructions, using translation when appropriate
Demonstrate the ability to communicate with patients from a wide range of backgrounds
Demonstrate professional and effective communication with nurses, staff, and colleagues (including other trainees and consultants)
Demonstrate professional and effective communication with transport personnel and receiving institutions/physicians during transfer to higher level of care
Demonstrate professional and effective verbal and written communication with primary care providers to ensure proper continuity of care
Demonstrate behaviors that are compassionate and respectful at all times

Practice-Based Learning and Improvement

Fellows are expected to investigate and evaluate patient care practices through appraisal of the literature, assigned readings, and assimilate this information in order to make appropriate patient management decisions.

The fellow is therefore expected to:

Demonstrate the ability to review current literature/guidelines and critically appraise topics related to pediatric urgent care medicine
Apply this knowledge to clinical decision making and clinical practice
Understand the process of quality improvement and its impact on clinical practice and health outcomes
Demonstrate ability to recognize deficiencies, accept and incorporate feedback and develop appropriate learning plans
Critically review medical documentation, to understand resource utilization, billing compliance, medical-legal concepts, and sound decision making
Develop teaching skills through the creation of lectures, workshops, medical simulation, bedside teaching, and other modalities

Systems-Based Practice

Fellows are expected to practice quality evidence-based health care that is cost-effective, and to understand the role of pediatric urgent care with the health care system.

The fellow will:

Demonstrate appropriate communication with primary care providers/medical home and consultants, including follow-up and continuity of care
Give and receive appropriate sign out at shift change
Practice cost-effective health care and resource allocation that does not compromise quality of care
Demonstrate the ability to provide high quality efficient medical care
Recognize the impact of efficient practice on patient flow and patient satisfaction within acute care setting
Understand EMTALA and legal issues related to patient transfers within a hospital-based system
Understand the capabilities of basic life support (BLS), advanced life support (ALS) and two-tier (BLS and ALS) systems
Understand the differences in prehospital provider training, including first responders, EMT-B, EMT-I, and EMT-P
Understand indications and advantages for air vs ground transportation

Professionalism

Fellows are expected to consistently exhibit a commitment to patient care, abide by ethical principles and be sensitive to diversity. They must have a respectful attitude toward their patients and colleagues.

The fellow is expected to:

Act in the best interest of patients
Exhibit a caring and respectful demeanor at all times
Maintain and advocate for patient/family confidentiality
Demonstrate respect for diversity in both patients, families and other members of the health care team
Observe professional standards of dress
Arrive on time, prepared for work
Complete medical records in an accurate and timely fashion
Willingly treat patients throughout the entire shift and beyond as needed
Advocate for the patient at all times
Treat patients and families with respect, and exude positivity
Use professional language at all times
Use language that respects the patient’s and family’s level of health literacy
Notify appropriate supervisor immediately if there are personal or other problems that prevent the fellow from carrying out his or her professional duties
Ensure adequate rest during time off to be prepared for work duties, ensuring adequate rest prior to driving home if one is too fatigued to drive safely