Infectious Diseases (Pediatric)

- The focus of this EPA is the application of the clinical skills acquired in Pediatrics to perform ID-specific consults. - This includes gathering an accurate history, including host/sociodemographic factors and relevant exposures; performing a physical examination; reviewing the results of pertinent investigations; synthesizing the information for an organized and concise presentation to a supervisor; and documenting the assessment. - An important aspect of this EPA is recognizing relevant infection prevention and control considerations and taking appropriate precautions. - At this stage, a complete and accurate management plan is not required.

Direct observation or review of case with supervisor Use Form 1. Form collects information on: - Type of observation (select all that apply): case review; directly observed history; directly observed physical exam; review of consult note - Setting: PICU; inpatient; NICU; outpatient - Patient with medical complexity/chronic medical conditions: no; yes Collect at least 2 observations of achievement - At least 1 directly observed history - At least 1 directly observed physical exam - At least 1 includes review of consult note - At least 2 different locations - At least 1 patient with medical complexity or chronic medical conditions - At least 2 different observers

- This EPA focuses on recognizing the potential severity of a patient’s presentation, performing a timely assessment and review of the case, initiating appropriate empiric management, and where relevant, engaging other services in the patient’s care. - Examples of life-, limb-, and/or organ-threatening presentations include meningitis, necrotizing fasciitis, malaria, sepsis/septic shock, serious CLABSIs, and other emerging infections. - This EPA may include attention to aspects of personal safety (e.g., infection control, violent patient). - An important aspect of this EPA is working within one’s limits and contacting senior residents/staff when appropriate.

Direct observation or case review by supervisor Use Form 1. Form collects information on: - Scenario (write in): - Setting: clinical; simulation Collect 2 observations of achievement - No more than one in simulation

Suggested observations: 2

- This EPA includes performing a history and physical exam for patients with a confirmed or suspected infectious disease and developing a plan for initial management, including selecting investigations, recommending appropriate PPE and isolation based on the clinical syndrome, and applying the principles of antimicrobial stewardship in the selection of treatment. - It may include working with the medical microbiology laboratory team in the investigation and management of the case and diagnostic stewardship of laboratory resources.

Case review by supervisor with confirmation of physical examination findings when relevant Use Form 1. Form collects information on: - Type of observation (select all that apply): direct; review of case; confirmation of physical findings - Demographic: neonate; infant; child; adolescent - Setting: emergency department; inpatient-medical; inpatient-surgical; NICU; outpatient; PICU - Organ system: cardiovascular; CNS; genital; GI; ophthalmic; osteoarticular; respiratory; skin and soft tissue; urinary; other (write in) - Post-surgical infection: no; yes - Retained hardware/foreign material: no; yes Collect 6 observations of achievement - At least 2 with confirmation of physical exam findings - At least 1 neonate or infant - At least 1 adolescent - At least 1 in medical inpatient setting - At least 1 in NICU or PICU setting - At least 1 in outpatient or emergency department setting - A variety of organ systems - At least 1 patient with a post-surgical infection - At least 1 patient with retained hardware/foreign material - At least 3 different observers

Suggested observations: 6

- This EPA focuses on the care that occurs over the course of a disease process. - This includes clinical reassessment, further investigation, and/or modification of treatment, including tailoring antimicrobial therapy, transitioning iv to po treatment, adjusting duration of treatment and responding to therapeutic drug monitoring as appropriate, and making decisions about discharge and/or follow-up. - It may include working effectively with a consulting service and facilitating access to treatments and resources (e.g., outpatient antibiotic therapy).

Case review by supervisor Use Form 1. Form collects information on: - Setting: emergency department; inpatient-medical; inpatient-surgical; NICU; outpatient; PICU - Issue: modify therapy based on incoming data and clinical response; manage complication or toxicity of therapy; sign-off of care with follow up as appropriate Collect 6 observations of achievement - At least 1 inpatient (NICU, PICU medical, or surgical) - At least 1 outpatient or emergency department - A variety of issues - At least 3 different observers

Suggested observations: 6

- This EPA includes summarizing case details, reviewing relevant investigations and treatment guidelines, identifying questions to be resolved through group discussion, and presenting the case in an organized and succinct manner. - It may include performing a literature review surrounding a pertinent aspect of the case and participating in shared decision-making about the case. - This EPA can be observed in case conferences within the infectious diseases group or in multidisciplinary meetings.

Direct observation by supervisor Use Form 1. Form collects information on: - Literature review done: no; yes Collect 2 observations of achievement - At least 1 involving a literature review surrounding a pertinent aspect of the case presented

Suggested observations: 2

- This EPA includes collecting and synthesizing clinical and epidemiologic information to formulate and prioritize a differential diagnosis, select investigations, and develop a treatment plan. - This includes applying knowledge of infection control, pharmacology, and antimicrobial stewardship as they pertain to the case and liaising with microbiology, public health, and other specialty services as appropriate. - Examples of a complex and/or chronic presentation include fever of unknown origin/non-infectious mimics, infectious complications of substance use, travel- related illnesses or other exposures and epidemiologic risk factors, patients who are immunocompromised (primary or secondary immunodeficiency), and patients with a critical illness (e.g., ICU, PICU, NICU) and/or with multiple concurrent medical conditions. - Examples of complex presentations include those that have inadequate source control, are not responding to usual therapy, or require special access to treatment (e.g., antimicrobial resistant organism).

Case review by supervisor or TTP resident Use Form 1. Form collects information on: - Setting: inpatient-medical; inpatient-surgical; NICU; PICU - Feature (select all that apply): ARO; asplenia; biologics/DMARDS; cancer/systemic therapy; complication of substance use; FUO/non-infectious mimic; HIV/AIDS; HSCT recipient; inborn error of immunity; neutropenia; pregnancy or the post-partum period; SOT recipient; suspected congenital infection; travel-related illness; other Collect at least 10 observations of achievement - At least 1 in inpatient-surgical setting - At least 2 in NICU setting - At least 1 in PICU setting - At least 3 immunocompromised patients, for two different reasons (HIV/AIDS, neutropenia, SOT recipient, HSCT recipient, biologics/DMARDS, inborn error of immunity, asplenia, cancer/systemic therapy) - At least 1 patient with a complex ARO - At least 2 patients with FUO/non-infectious mimic - At least 1 patient with a suspected congenital infection - At least 1 travel-related illness

- This EPA includes reassessment of the patient to evaluate changes in their clinical condition, interpret results of new investigations, assess response to therapy, and identify any complications and side effects. - It also includes recognizing the need to tailor therapy and formulate a plan for ongoing monitoring, follow-up, and completion of treatment as an inpatient or outpatient. - This may include liaising with the referring physician, microbiology, public health, and other specialty services as appropriate.

Case review by supervisor, TTP resident, or ID pharmacist Use Form 1. Form collects information on - Issue: modify therapy based on incoming data and clinical response; manage complication or toxicity of therapy; sign-off or transfer of care with follow up as appropriate Collect 12 observations of achievement - At least 6 of modifying therapy based on incoming data and clinical response - At least 2 of managing complications or toxicity of therapy - At least 4 sign-off or transfer of care with follow-up as appropriate - At least 3 different observers

Suggested observations: 12

- This EPA focuses on providing care in the outpatient setting, including initial consultation and/or ongoing management. - This includes assessment of the patient’s condition and development of or reassessment of the treatment plan which may include surveillance for complications of the infection or its treatment, monitoring of therapy and response to therapy, and plans for follow-up. - It also includes addressing patient/family concerns and providing education, applying knowledge of resources in the outpatient setting, and helping patients/families access those resources when needed. - This EPA includes approaching patients with an attitude of inclusion, respect for diversity and cultural humility and advocating with patients experiencing stigmatization and/or complex social situations, such as barriers to accessing care or guardianship/substitute decision maker issues. - This EPA may be observed in a variety of clinics such as general ID, outpatient antibiotic therapy, specific infections (TB, etc.).

Case review by supervisor Use Form 1. Form collects information on - Type of visit: new consult; follow-up - Presentation: congenital infection; MRSA decolonization; HIV; post-infectious syndrome; recurrent infections; TB; undiagnosed signs/symptoms; other - Immunodeficiency workup initiated: no; yes - Social complexity: no; yes Collect 12 observations of achievement - A mixture of new consults and follow-up visits - A variety of presentations - At least 1 patient with a congenital infection - At least 1 patient with HIV infection - At least 1 patient with TB infection - At least 1 where an immunodeficiency workup was initiated - At least 1 case with social complexity

Suggested observations: 12

- This includes performing a clinical assessment and providing counselling, guidance, and preventive care. - Examples include pre- or post-splenectomy, pre-travel, and vaccine recommendations; counselling in the context of vaccine hesitancy; pre- and post- exposure prophylaxis (immune or chemoprophylaxis); and harm reduction consultations. - The observation of this EPA includes at least one observation of counselling for vaccine hesitancy; this may be observed in a simulation encounter if clinical opportunities are not able to be provided.

Case review with supervisor Use Form 1. Form collects information on - Presentation: immunosuppression, transplant, or splenectomy (pre or post); infant of mother living with HIV; pre-exposure prophylaxis/harm reduction; pre-travel counselling; post-exposure prophylaxis; vaccine hesitancy counselling - Direct observation of counselling: no; yes Collect 5 observations of achievement - At least 1 immunosuppression, transplant, or splenectomy presentation - At least 3 of any of the other presentations - At least 1 direct observation of vaccine hesitancy counselling - At least 2 different observers

Suggested observations: 5

- This EPA focuses on providing consultation regarding an infection control question posed by infection control practitioners or other health care professionals. - This includes gathering and/or reviewing clinical information about the request and synthesizing clinical data with results of investigations to develop an understanding of the clinical question and make recommendations about infection control procedures and case and contact management as relevant. - This EPA may be completed during the IPAC rotation. - This EPA may be observed in simulation.

Direct observation or case review by supervisor or IPAC practitioner (if delegation deemed appropriate by the rotation supervisor) Use Form 1. Form collects information on: - Case mix (select all that apply): airborne pathogen; antimicrobial resistant organism; blood borne; decontamination/sterilization issue; emerging/re-emerging pathogen; gastrointestinal; pathogen of public health importance; respiratory virus; other - Simulation: no; yes Collect 3 observations of achievement - A variety of the case mix - No more than 1 in simulation

Suggested observations: 3

- This EPA focuses on applying the principles of antimicrobial stewardship. - This includes efficiently gathering information needed to determine the appropriateness of an antimicrobial regimen, deciding if the case warrants a formal infectious diseases consult, providing oral and/or written recommendations, and working effectively with the most responsible clinical team. - The observation of this EPA is based on a stewardship round (in any setting) or a review of antimicrobial usage over a specific unit of time or in a specific clinical setting.

Direct observation and review of documentation with supervisor, pharmacist, or TTP resident Use Form 1. Collect 1 observation of achievement

Suggested observations: 1

- This EPA focuses on the application of written communication skills in a variety of formats, such as consultations and progress notes. - This includes a synthesis of the pertinent clinical findings, investigations, and management plan, as well as clear articulation of the rationale for the treatment plan and education around pertinent issues, including concepts of antimicrobial stewardship, microbiology, and pharmacology. - It may include linking the recommendations to evidence-based guidelines or other educational references for the referring physician. - The documents submitted for review must be the sole work of the resident.

Review of clinical documentation by supervisor Use Form 1. Form collects information on: - Document: inpatient consultation; inpatient progress note; outpatient consultation; outpatient progress note; sign-off, discharge, or transfer note Collect 5 observations of achievement - At least 3 different types of documents - At least 2 different observers

Suggested observations: 5

- This EPA focuses on the application of advanced communication and/or conflict resolution skills to address difficult situations that involve patients, families, and/or members of the health care team. - Examples include informing a patient/family about a serious diagnosis or prognosis; explaining a complex management plan; disclosing an adverse event or unexpected complication; addressing confrontational behaviour with a patient or family; dealing with a patient or family complaint; and difference of opinion with another care provider.

Direct observation by supervisor, which may include input from the patient, family, and/or other members of the health care team Use Form 1. Form collects information on: - Issue related to: patient/family; team/other health professionals; other - Scenario (write in): Collect 3 observations of achievement - At least 1 issue related to a patient/family - At least 1 issue related to the team/other health professionals - A variety of scenarios - At least 2 different observers

Suggested observations: 3

- This EPA focuses on formal and informal teaching presentations to diverse audiences such as patients, families, junior and senior learners, and other health professionals. - This includes aligning the material and language to the needs of the audience and demonstrating effective presentation skills. - In clinical settings, it includes maintaining a respectful and positive learning environment for both learners and patients when learners are involved in their care.

Direct observation by supervisor, which may include input from the learners/audience; or collated feedback from the learners/audience Use Form 1. Form collects information on: - Teaching activity: academic half-day; bedside teaching; clinical rounds; journal club; other formal rounds; other - Audience (select all that apply): ID residents; junior resident/medical students; staff physicians; other health care professionals; patients and/or families; public Collect 4 observations of achievement - At least 3 different activities - At least 1 formal rounds - At least 2 different observers

Suggested observations: 4

- This EPA focuses on the learner’s ability to function effectively in the outpatient setting, including balancing the clinic load while making appropriate clinical decisions, managing time appropriately, and working effectively with other health professionals. - The observation of this EPA is based on at least a half day of clinic.

Direct and/or indirect observation by supervisor, with input from nurses and other staff in the clinic Use Form 1. Form collects information on: - Type of clinic: general ID; longitudinal; OPAT; specialized ID; other - Setting: hospital; community Collect 3 observations of achievement

Suggested observations: 3

- This EPA includes all aspects of leading a consultation service, including triaging referrals, delegating to and organizing the work of junior members of the team, providing consultation and follow-up care, working effectively with referring physicians, and making decisions for patient care. - The observation of this EPA is based on a period of at least one week.

Direct and indirect observation by supervisor Use Form 1. Collect 3 observations of achievement - At least 2 different observers

Suggested observations: 3

- This includes medical care decisions and follow-up on investigations, preparing appropriately for clinic, providing all relevant aspects of care at and between patient visits, rescheduling if tests are incomplete or patient does not attend, and working effectively with the other health care professionals. - It also includes appropriate accessibility in between clinic visits and arranging for coverage by another physician while away. - This EPA should be observed in general ID clinic and/or longitudinal resident clinic. - The observation of this EPA is based on the resident’s performance over a month or more, with observations documented at intervals of at least one month (i.e., not based on a single clinic, but rather on the resident performance over time).

Direct and indirect observation by supervisor(s), which may include input from nurse, clinic manager, administration staff, patients and/or families Use Form 1. Collect at least 3 observations at intervals of at least one month; with at least 1 observation of achievement

- This EPA focuses on providing appropriate and timely advice about management and/or patient disposition as well as recognizing conditions that can be managed remotely (by telephone, video or virtual) versus those that require in-person assessment. - It also includes keeping appropriate documentation of the interaction and guidance provided; it may include billing for the encounter. - This EPA includes responding to unscheduled calls from physicians and other health care professionals within the same institution and from outside hospital or clinical settings.

Direct observation or case review and review of clinical documentation by supervisor Use Form 1. Form collects information on - Source: health care worker at same institution; health care worker from an outside hospital or clinic setting Collect 2 observations of achievement - At least 1 from an outside setting

Suggested observations: 2