CHAPTER 1
NEONATAL SERVICES
I. NEWBORN INTENSIVE CARE UNIT (NICU)
A. The Children’s Hospital NICU of the Greenville Hospital System (GHS) functions as a regional Level III (tertiary care) referral intensive care nursery for approximately 14,000 births per year from a six-county area in upstate South Carolina. All direct patient care will be provided and organized by the Resident Housestaff and by the GHS neonatal nurse practitioner (NNP) staff under the supervision and direction of the Attending staff. In other instances, infants may be admitted to the NICU under the direction of the Pediatric Surgery service or a primary-care pediatrician.
B. Our NICU is currently a licensed 80-bed facility on the 6th floor of the Children’s Hospital. It has recently expanded resulting in NICU I and NICU II. There are 37 designated Intensive/Intermediate care beds in NICU I, 16 Intermediate/Intensive care beds in NICU II as well as 17 level II beds for late preterm and term infants with clinical problems that cannot be managed in the Newborn Nursery and a Family Learning Center consisting of 10 rooms in NICU II where parents may stay for one or more nights to learn the care of their soon-to-be discharged infant.
C. On average, there are 750 - 950 admissions per year to our NICU. Eighty-five percent (85%) of our admissions are inborn patients. The survival rate over the past 4 years has been > 95% for all admissions (realizing that more premature infants and critically ill term infants may be at increased risk for mortality).
E. Data on birth weight and gestational age specific mortality are available at:
http://www.pediatrix.com/workfiles/clinicalresearch/EGA_BW.pdf
http://www.pediatrix.com/workfiles/clinicalresearch/WO_Morbidity.pdf
https://www1.nichd.nih.gov/epbo-calculator/Pages/epbo_case.aspx
II. RESIDENT PHYSICIAN LEARNING OBJECTIVES AND RESPONSIBILITIES
A. Objectives: By the end of the third year (or three NICU rotations), the Pediatric Resident should feel comfortable and knowledgeable with the following procedures and newborn disease processes:
1. Core Procedures
a. Evaluation and stabilization of the term newborn infant in the delivery room.
b. Evaluation and stabilization of the preterm infant in the delivery room.
c. Confidence and ability to coordinate and run a neonatal code resuscitation.
d. Ability to properly intubate any infant in respiratory distress.
e. Ability to properly intubate an infant who requires aspiration of meconium or installation of artificial surfactant.
f. Ability to properly insert an umbilical venous (UV) or arterial (UA) catheter.
g. Ability to properly perform and interpret a neonatal lumbar puncture.
h. Ability to properly perform a needle aspiration and chest tube insertion for an infant with a tension or otherwise compromising pneumothorax.
i. Ability to appropriately order and interpret routine neonatal chest and abdominal X-rays.
j. Ability to properly screen and/or treat an infant at risk for sepsis.
2. Knowledge
a. General Perinatal Medicine
The learner should:
• Gain knowledge and understanding of perinatal risk factors, including factors predisposing to preterm delivery and maternal risk factors affecting the fetus.
• Be able to review the specific maternal risks associated with early teen pregnancy and pregnancy after age 35, multiple gestational pregnancies, diabetes in pregnancy, hypertension in pregnancy, hydrops in pregnancy, erythroblastosis fetalis, and perinatal infections.
• Be able to discuss fetal physiology and perinatal monitoring techniques and maternal and fetal laboratory testing.
• Be able to identify the risks associated with delivery of infants including breech deliveries, shoulder dystocias, use of mechanical assistance devices, and Caesarean section.
b. General Neonatal Care
The learner should:
• Possess knowledge and understanding of basic neonatal care requirements for term and preterm infants including temperature regulation, basic free water requirements, basic electrolyte requirements, mineral needs, and caloric requirements.
• Be able to order and manage enteral and parenteral nutrition for any neonate.
• Have a general understanding of the normal vital sign ranges for all types of infants in an NICU setting and understand normal neonatal thermal regulation.
• Understand general radiological principles and how to interpret basic neonatal chest and abdominal X-rays.
c. Central Nervous System Knowledge
The learner should:
• Possess knowledge and understanding of basic embryological brain development.
• Be familiar with the following pathological conditions:
-- Intraventricular hemorrhage (IVH)
-- Periventricular leukomalacia (PVL)
-- Other acute brain vascular accidents
-- Hypoxic-ischemic encephalopathy (HIE)
-- Seizures in the newborn
-- Hydrocephalus
-- Perinatal and newborn central nervous system (CNS) infections
-- Congenital brain malformations
-- Congenital neuromuscular disorders
-- Meningomyelocele
and understand evaluation techniques and treatment options for each of these diseases (including imaging techniques such as MRI, CUS, and cranial CT.
• Understand risk factors associated with subsequent development of cerebral palsy and/or mental retardation and the importance of neonatal developmental follow-up.
d. Respiratory System Knowledge
The learner should:
• Understand and develop management plans for infants with:
-- Respiratory distress syndrome (RDS)
-- Transient tachypnea of the newborn
-- Pneumonia
-- Aspiration syndromes
-- Bronchopulmonary dysplasia, BPD
-- Pneumothorax
• Understand the embryology and management of congenital malformations of the lung, including:
-- Diaphragmatic hernia and other lung hypoplasias
-- Cystic adenomatoid malformation
-- Congenital emphysema and other cystic malformations
-- Tracheoesophageal fistulae
-- Alveolar capillary dysplasias
• Understand the physiology of pulmonary surfactant systems and the clinical utilization of artificial surfactants.
• Understand the risks for and management options for persistent pulmonary hypertension of the newborn (PPHN).
• Understand upper airway complications.
• Have a good understanding of the basic ventilators and ventilator strategies employed in our NICU.
• Know how to properly interpret blood gases, oxygen saturations, and transcutaneous pCO2 measurements.
• Understand surfactant uses and normal pulmonary function values for the preterm and term infant.
• Understand the differential diagnosis associated with apnea of prematurity and the management strategies for neonatal apnea.
e. Cardiovascular System Knowledge
The learner should:
• Understand basic cardiac embryology.
• Understand normal and abnormal neonatal cardiovascular hemodynamics.
• Understand basic cyanotic and non-cyanotic congenital heart disease and how to medically manage individual cases both acutely and chronically.
• Be able to calculate intravenous drips of vasopressors or vasodilators.
• Understand common neonatal arrhythmias, how to interpret electrocardiograms (EKGs), and the use of drugs or other interventions to manage arrhythmias.
• Understand who is at risk for persistent patent ductus arteriosus (PDA) and the risk and treatment of this problem.
• Appreciate the difference between common neonatal murmurs.
f. Blood and Hematopoietic System Knowledge
The learner should understand:
• Common neonatal hematopoietic disorders, including:
-- Anemia
-- Thrombocytopenia
-- Neutropenia
-- Coagulopathy
• More rare complications associated with polycythemia, thrombocytosis, and neutrophilia.
• The proper preparation and ordering of blood products for the neonate.
• Graft-versus-host disease in the neonate.
g. Immune System Knowledge
The learner should understand:
• Common perinatal infections and how to evaluate and manage them.
• Early-onset sepsis and nosocomial infections in the neonate.
• Antibiotic, antiviral and antifungal regimens and dosing in the neonate.
• Risks associated with vertical and horizontal transmission of disease in the neonate.
• The evaluation and management of the “rule-out sepsis infant.”
h. Gastrointestinal (GI) Tract and Liver Disease Knowledge
The learner should understand:
• Basic gastrointestinal developmental embryology.
• Common neonatal GI pathology, including:
-- Malrotation
-- Volvulus
-- Omphalocele
-- Gastroschisis
-- TE fistulas
-- Atresias
-- Hirschprung’s disease
-- Gastroesophageal reflux (GER)
-- Meconium ileus
• Risk factors and management strategies for necrotizing enterocolitis (NEC).
• Management of the infant with short bowel syndromes.
• The evaluation and management strategies for the infant with elevated indirect and/or direct hyperbilirubinemia.
• Basic congenital liver diseases.
i. Renal System Knowledge
The learner should:
• Understand basic renal embryology.
• Understand common developmental abnormalities, including:
-- Hypospadias
-- Posterior urethral valves
-- Ureteropelvic junction (UPJ) and ureterovesicular junction UVJ obstructions
-- Hydronephrosis
-- Parenchymal malformations
• Appreciate the genetic risks of recurrence.
• Understand basic urine output requirements for neonates and disorders in urine electrolytes and renal function tests.
• Understand syndrome of inappropriate secretion of antidiuretic hormone (SIADH) and diabetes insipidus in the neonate.
• Understand renal dosing requirements for neonatal drugs.
j. Other Organ System Knowledge
The learner should understand:
• Basic endocrine function of the neonate, including thyroid function and disorders of calcium, phosphorus and magnesium.
• Management of the infant with hyperinsulinemia.
• How to manage an infant on an insulin drip.
• Common skin disorders and proper skin care for the neonate.
• Basic eye diseases, including cataracts, congenital glaucoma, and retinopathy of prematurity (ROP).
• Common neonatal orthopedic disorders.
• Common neonatal genetic syndromes and chromosomal disorders.
• Basic acid-base physiology and common congenital metabolic disorders and how to evaluate for and manage them.
Diagnostic Testing (NICU)
The learner should understand:
• Indications for, limitations of, and interpretation of common diagnostic and imaging studies used in the NICU. Know gestational age appropriate normal laboratory ranges. Understand cost and utilization issues.
• Diagnostic test properties including use of sensitivity, specificity, positive predictive value, negative predictive value, likelihood ratios, odds ratios and relative and absolute risk.
• Common maternal screening labs including HIV status, RPR or VDRL results, blood type and antibody screening, CF screening results, AFP results, maternal drug screening results and fetal lung maturity results.
• Common X-rays obtained in the NICU to assess ET placement, PICC line placement, UAC and UVC placement. Know when to order X-rays, ECHOs, MRIs, ultrasounds, etc.
• Common NICU blood tests including CBC with differential, blood chemistries, blood glucose, renal and liver function tests, C-reactive protein, drug concentration monitoring, serological tests for infection, coagulation studies, blood gas tests, urinalysis, CSF analysis, gram stains, stool studies, state newborn metabolic screening
Procedural and Therapeutic Modality Competencies (NICU)
The learner should understand:
• Common monitoring and therapeutic modalities used in the NICU including oximetry, apnea monitoring, cardiorespiratory monitoring, inhaled nitric oxide, ventilatory support options (high flow nasal cannula, CPAP, conventional ventilation and HFOV), and pCO2 monitoring.
• Common use and skills in providing Neonatal resuscitation in the delivery room, intubation, umbilical line placement, peripheral arterial puncture techniques, needle aspiration of the thorax and abdomen, chest tube insertion, suprapubic stick, lumbar puncture.
• Common use of home medical equipment including oxygen, apnea monitoring, G-tube equipment, tracheostomy equipment, home ventilators and home hyperalimentation. Be able to provide support and education for use of maternal breast pump use.
m. Ethics in the NICU
The learner should understand:
• Common ethical dilemmas in the NICU and how best to resolve these events.
• Parental rights laws.
• The importance of and develop plans for obtaining informed parental consent.
• That the delivery room is never the ideal place for acute decisions to be made about whether an infant is non-viable or not. A resident should never be solely responsible for these decisions. To quote from Norman Fost in Fanaroff and Martin’s 7th Edition of Neonatal-Perinatal Medicine (2001), “... the usual recommendation is to stabilize all live born infants and then to transfer them to the intensive care unit where they can be fully assessed. If the infant is truly non-viable, or if it is not in the child’s interest to be maintained, there will nearly always be some life-sustaining treatment that can be discontinued.”
B. Specific Daily Responsibilities for the PL-1 Pediatric Resident (also includes Family Practice Residents or Transitional Year Residents)
1. This individual will be the primary care physician for patients in the NICU. This physician will be expected to evaluate his/her patients, develop clinical management plans, and implement these plans under the guidance of the PL-2 or PL-3, NNPs and Attending Neonatologists. These responsibilities include:
a. Completing an admission note on EPIC as soon as possible after admission.
b. Entering at least one progress note per patient per day.
c. Writing procedure notes for umbilical line placement, intubation, lumbar puncture, etc. Each procedure note should be accompanied by a statement acknowledging that parents were informed of details related to any non-emergent procedure and that they have given consent for this procedure.
d. Presenting patients at morning rounds to the Attending Neonatologist(s). Presentations should be concise. Organization of the presentation should follow the flow sheet at the patient’s bedside. An example:
1. Patient’s name, post-menstrual age, and the number of days after birth
2. Patient’s current weight and gain (loss) from previous day
3. Previous day’s vital signs, including fluid intake (mL/kg/day) and urine output (mL/kg/hour)
4. Number and type of apnea and bradycardia events
5. Discussion by problem (should be individualized for each patient, (e.g., there is no need to discuss every system in an otherwise stable infant). Specifics included should highlight any system failure or improvement, pertinent lab values, medications needed and plan for the day. Problems that are often discussed are listed below:
-- RDS/BPD
-- Nutrition Assessment
-- Apnea of Prematurity
-- Actue Renal Failure
-- Jaundice
-- Sepsis
-- Anemia
-- Other (e.g., social)
f. Writing all orders and informing bedside RN or respiratory therapist (RT) that an order has been written.
g. Performing all procedures as appropriate and with supervision as needed.
h. Communicating with parents frequently by phone and/or at bedside (attempt daily communication with your most critically ill patients and at least 2 times per week for intermediate patients).
i. Discharge and social planning - discussing each admission as soon as possible with the NICU social worker. Discharge planning should be planned as far in advance as possible with the Attending Neonatologist, Social Worker, and the patient’s primary nurse. PL-1 residents will need to contact (talk to) all follow-up physicians prior to discharge, Kathy Gentry discharge coordinator can also assist with arranging outpatient follow-up.
j. Performing check-out rounds that will start in the afternoon (4:00 - 4:30). Once all routine daily responsibilities are completed and notes written, a plan for overnight management should be formulated. This plan should be discussed among the neonatologist and the resident or NNP on call.
k. Other specific patient responsibilities include:
-- PL-1s may have up to 8 patients on their weekday clinical service. These numbers will vary depending on census (i.e., if the census gets very high, your patient load may increase) and NNP/other resident coverage. The patients carried by the PL-1 will usually be more stable infants.
-- On weekdays, preliminary rounds should be performed on each of your primary patients before morning rounds, which start at approximately 9:30. Typically, this will mean that you must arrive by 7:00 am.
-- Weekend service typically requires the PL-1 or NNP on call to round on the majority of the intensive patients as their primary responsibility (patient load may be up to 15 patients). Rounds begin at the same time as weekdays, but because weekend responsibilities require you to know about most of the sicker infants (who may not be your responsibility during the week), you may have to arrive earlier in order to be ready for rounds.
-- A resident may leave the NICU early (i.e., when they are post call or for other Resident designated responsibilities), provided that sign-outs to the remaining resident or NNP are complete and appropriate.
-- During the first month of a first-year resident’s duty, the resident’s goals should be to:
• Become thoroughly oriented to the NICU
• Be able to perform a physical exam and assessment of the neonate
• Gain increased understanding of basic pathophysiology of neonates
• Participate in delivery room resuscitation/stabilization of high-risk neonates
• Perform procedures (e.g., intubation, umbilical catheter placement)
• Attend cesarean births with supervision
• Learn neonatal nutritional needs (e.g., parenteral and enteral feeding regimens)
• Identify problems and develop care plans, including long- and short-term goals for each problem
• Participate in discharge planning for your patients
• Serve as the primary medical communicator about your patients with parents/referring physicians.
-- Night back-up: Emergencies should be immediately communicated to the Attending in-house physician. Anticipation of a high-risk delivery requiring Neonatology support should be relayed to the Neonatologist on call ASAP. Other concerns or questions about patient management should be communicated to the Neonatologist on call without hesitation.
-- Absence from rotation: Any elective absence from a scheduled NICU rotation must be approved by both Dr. Grisham (or Dr. Kolarik for Med-Peds Residents) and Dr. Halliday or Dr. Ruggieri. Some of these absences may require the PL-1 to obtain resident cross-coverage from their colleagues in order for the PL-1 to leave the NICU rotation. Extended absences beyond a few days may also require the PL-1 to make up the lost time on subsequent rotations
Finally, three additional pertinent caveats to remember are:
(1) Never antagonize the NNPs, RTs, nurses, Social Workers, ward secretaries, or laboratory technicians (these are your friends, support system and allies)!
(2) Don’t make disparaging (pessimistic) comments about patients - especially in front of parents!
(3) Appreciate the medico-legal importance of maintaining patient confidentiality!
Our NICU is a close-knit group of people who have worked hard to make this an outstanding neonatal unit. They also are a group who, for better or worse, will relay a negative experience about a resident to other members of the team perhaps subjecting a resident to a bias he or she doesn’t deserve. If you are experiencing personality conflicts (and they will happen on occasion), be tactful and pursue grievances through the appropriate channels:
Routine day-to day nursing issues should be addressed with the daily charge nurse. Other NICU personnel include:
• Head Nurse Manager: Karen Merritt, RN, MBA, BSN, AAB
• NNP coordinator: Deborah Lynch, MSN, NNP-BC
• NICU Respiratory Therapist Clinical Supervisor: Suze Westmoreland, RRT
• Laboratory Technician Supervisor: Karen Greene, MT
• Attending Neonatologist Liaison: Matt Halliday, MD; Jeffrey Ruggieri, MD (however, don’t hesitate to express your immediate concerns with the Attending Neonatologist on service)
C. Responsibilities for the PL-2 or PL-3 Pediatric Resident
1. Acts as a preceptor for first-year residents (e.g., attends deliveries, helps with procedures, helps with order writing, helps in writing daily notes, coordinates discharge planning). These requirements will be limited for the post-call PL-2 or PL-3 (e.g., an NNP or Attending will assist the PL-1).
2. Attends Attending/resident rounds, as well as other scheduled rounds. The PL-2/3 should also accompany the Attending Neonatologist to parent conferences (antenatal and postnatal) as time permits.
3. Carries a patient load consisting of 8-10 infants. The PL-2/3 will remain responsible for all admissions that occur on his or her day on call (including delivery attendance, performing procedures, writing orders and admission notes, and developing a post-call treatment plan.
4. PL-2/3 residents are strongly encouraged to begin to review the pertinent neonatal literature emphasizing an evidence-based medicine approach where applicable. Short presentations of pertinent topics and literature reviews will merit “bonus consideration” based on their quality. Any PL-2/3 who demonstrates an aptitude in this area will merit consideration for an “excellent” rotation evaluation score.
III. ALLIED HEALTH CARE PERSONNEL AND PROGRAMS
A. Neonatal Nurse Practitioners: These individuals have had additional specialized training (many have their Masters degree) and have passed a nationally administered certifying test in high-risk neonatal care. They are very skilled in resuscitation and NICU procedural skills. They also have an outstanding knowledge base. Their function in our NICU is to assist the Neonatologists with the daily assessment and plan of care for selected infants on their team (the other infants being the responsibility of the residents). They are also part of our education team and can assist in answering Resident questions and concerns.
• Coordinator: Tyner Lollis
-- Deborah Lynch
-- Charlene Wells
-- Treasure Snyder
-- Dawn Allen
-- Catherine Wilson
-- Karen Covington
-- Ara Messemer
-- Kyle Weir
-- Jamie Bott
-- Melissa Dunham
• Nurse Manager : Karen Meritt, RN, MBA, BSN, AAB
• Nursing Supervisors:………………………………Ashley Childress, RN, Dana Batty, RN, Nancy Satterfield, RN, Monica Kates, RN
Adjunct Nurse Educator for orientation Carol Whitten, RN
• Clinical Nurse Specialist (nurse educator): Susan Chamberlain, RN
• Head Transport Nurse: Mary Sansbury, RN
-- Each infant is assigned to a primary nurse within 48 hours of admission.
-- He/she will plan 24 hour nursing care, maintain contact with family and plan for discharge.
-- It is essential that residents coordinate care with this nurse.
-- Primary nurses should be invited to parent conferences.
-- Each shift has a charge nurse who will facilitate nursing attendance and input at rounds.
-- Bedside nurses are assigned for 12 hour shifts and are responsible for care and observations and alerting doctors to subtle or obvious changes.
C. Pediatric Respiratory Care (the NICU Respiratory Therapy Shift Coordinators are Amanda Egli, RRT, Jonathan Miller, RRT, Brian New, RRT, and Jon Johnson, RRT
1. Our respiratory therapy group is comprised of nationally certified individuals, often with several years experience in neonatal respiratory care. They provide 24-hour coverage, 7 days a week in the NICU. Their responsibilities include:
a. Evaluation of respiratory equipment for safety, consistency, efficiency and effectiveness. They are responsible for set-up, monitoring and maintenance of all oxygen delivery and ventilatory assistance devices.
b. Performing ordered ventilatory adjustments and recommending changes in equipment and therapy when needed.
c. Assessing patient’s respiratory status (breath sounds, arterial blood gases (ABGs), etc.) and effectiveness of therapy.
d. Assisting with the development of respiratory care policy and procedure
e. Performing intubations as needed for credentialing or in emergent situations
f. Assisting with and/or performing special studies related to respiratory care including drawing of arterial blood gases from umbilical arterial catheters (UACs) and peripheral arterial lines.
g. Facilitating communication among therapists, medical technologists, nurses and physicians.
h. Developing and assisting in management of respiratory care protocols and research projects (such as our ventilatory weaning protocol for all infants on conventional ventilatory support).
2. Always notify the therapist in cases of respiratory emergencies, intubations or extubations in order to ensure appropriate assistance.
3. Always notify respiratory therapist when a respiratory order is written. The respiratory care orders are on a clipboard at the bedside (not in the blue chart).
D. NICU Laboratory Medical Technologists
1. These individuals are trained and certified and provide around-the-clock coverage, 7 days a week. Their duties include:
a. Obtaining and processing all blood specimens on all lab tests ordered with the exception of blood cultures (obtained by the bedside nurse, resident, or NNP) and arterial blood gases (obtained by RT or attending physician).
b. NICU laboratory evaluation includes: blood gas analysis, electrolytes, bilirubin, glucose and hematocrit.
c. Delivering NICU and main lab results to the patient’s bedside.
d. Calibrating, maintaining and performing quality assurance on all lab equipment.
2. Communication System
a. The house staff and NNPs are responsible for writing all lab orders, including routine labs (glucose and hematocrit), which are determined by the “status” of the patient, e.g., “high-risk” vs. “low-risk”. STAT orders will be processed as soon as they are collected; otherwise all labs are obtained with the morning blood draws.
b. Time-specific lab values (medication levels) must be ordered to be drawn at a certain time.
c. Lab orders should specify frequency and/or specific times for lab work to be drawn (e.g. Q 12 hrs or M-W-F).
d. Daily lab orders should be reviewed and “discontinued” when no longer appropriate.
e. Lab techs are not allowed to take verbal orders from the patient care staff.
f. Occasionally, the laboratory staff will need back-up help. Examples include an inability to obtain a sufficient quantity of blood or if a NICU laboratory analysis machine fails (getting it up and running is a top priority in their job description).
E. Social Services
1. Two social workers are assigned to the Mother-Baby Unit of the Greenville Hospital System, currently Whitley Mann, MSW. They should be consulted on every admission and should be re-consulted at least 5-7 days prior to any hospital discharge or transfer (whenever possible). They are responsible for placing a family evaluation on the chart within a few days of admission. This reference provides valuable social information and phone numbers where family members can be contacted. The social workers should be kept abreast of any relevant social/parental concerns and should help coordinate and attend any parent conference. They will also be responsible for any physician ordered home equipment arrangements and/or home nursing requirements. At night or on weekends, there is also a social worker on call 24 hours a day for pediatrics.
Pharmacy
Bethany Lynch, Pharm D is the clinical pharmacist for the NICU. She rounds on
patients with the team and adds valuable input regarding the management of medications in the NICU including levels, weaning medications, medication protocols, etc.
G. Nutrition
Billy Watkins is the Dietician dedicated to the NICU exclusively.
IV. NICU DAILY ROUTINES
A. Orders
1. Current order sheets (except for respiratory orders) and patient charts are kept at the patient bedside. All orders require the patient name and weight to be on the order sheet. All medications, intravenous feedings (IVFs), TPN, feeding, laboratories, consults, specialty requests (e.g., chest X-ray (CXR), echocardiogram (ECHO), cranial ultrasound (U/S)), blood product transfusions, and change in care status orders are written in this chart in black ink (photocopies much better than any other color). Please designate as STAT (to be performed in < 1 hour) those orders that must be performed immediately and notify the patient’s nurse.
2. All medication orders must be written as milligrams or micrograms per kilogram per dose (or micrograms/kg/min) whenever applicable.
3. Ventilator, oxygen and respiratory treatment orders are written in the neonatal ventilator order.
4. TPN orders prepared by the pharmacy must be entered by 12:00.
5. No verbal orders are permitted, except in emergencies and these must be signed ASAP.
B. Rounds
1. There are 3 separate attending Neonatologists for the Resident and NNP teams. Additionally, there is usually a Delivery Room Attending who assists with deliveries, consultations and admissions during the weekdays.
2. Attending rounds are held seven days a week in intensive beginning at approximately 9:30 on weekdays and between 9:00 - 10:00 am on weekends. Residents and NNPs should have already pre-rounded on their patients and be prepared to present them.
3. We will attempt to hold teaching rounds (for everyone) in the early morning or late afternoon on 3 weekdays per week. This is usually a short discussion of a clinically relevant topic.
Rounds should not be interrupted except for emergency situations. To help avoid interruptions, the Delivery Room attending will assist with acutely deteriorating infants, attend deliveries and tend to admissions to preserve the morning rounds.
V. CLINICAL PROTOCOLS RELEVANT TO PREMATURE INFANTS (See "Protocols" Tab for complete details: regarding these protocols).
CRANIAL ULTRASOUNDS for all infants < 31 weeks’ estimated gestational age (EGA) or < 1500 grams birth weight (and other selected patients)
EYE EXAMS TO EVALUATE FOR THE PRESENCE OF RETINOPATHY OF PREMATURITY (ROP) OR OTHER DISEASES OF THE EYE. For all infants < 1500 grams birth weight and/or < 31 weeks gestational age (and other selected infants).
AUDIOLOGY EXAM for all infants prior to discharge.
BLOOD TRANSFUSION PROTOCOL
Because transfusion of blood products is a sensitive issue for parents, a handout (handouts are also available for a host of other procedures and therapies) has been prepared and should be given to all parents upon admission of their infant to the NICU. It discusses risks/benefits of blood transfusions in a fashion that is easily understood by the average lay person. All infants must have a blood sample for type and cross-match (minimum 1 cc) sent to the GHS blood bank prior to any blood product transfusion.
VI. SPECIAL PROCEDURES
A. Stable infants leaving the NICU must be accompanied by an NICU nurse.
B. Unstable infants must be accompanied by a nurse and a physician (a member of the transport team may be an acceptable alternative in selected instances).
C. Notify nursing 24 hours ahead of schedule, when possible.
D. If not possible, notify nursing as soon as the decision to do procedure is made.
VII. DELIVERY ATTENDANCE
Delivery attendance is requested by Labor and Delivery (L&D) in selected cases. Medium-risk deliveries may be attended by a PL-2/3 (after the first month’s rotation) without additional assistance. Please make note of equipment needs in L&D or the C-section suites and report any deficiencies to the L&D charge nurse immediately. The Resident should be aware that they may request assistance by the NICU resuscitation team (see below) for any delivery. High-risk deliveries are attended by the NICU resuscitation team, which consists of a Resident or NNP, an NICU nurse, and an RT. An attending Neonatologist will also attend any high-risk delivery.
VIII. ADMISSIONS, IN-HOSPITAL TRANSFERS & TRANSPORTS
A. All incoming phone calls about possible transports should be referred to the Delivery Room Attending (or night call) Neonatologist. A special transport form is available at the front desk (usually found in a Transport Notebook at the Front Desk). It should be filled in when a phone call is being taken from a referring physician. The charge nurse and the Attending will discuss census problems and/or staffing needs for the transport babies.
B. Back Transports (step-down transports) -- Purpose and Procedure
1. To facilitate parent-infant bonding by shortening distance parents must travel to visit their baby, to lessen hospitalization costs for a convalescing child who no longer needs intensive care, and to fully utilize the regional system of perinatal care.
2. In order to optimize back transports, the Resident or NNP should find out if the receiving hospital has the staff and technical capability to manage this infant, what the visitation policy for the parents will be, and where this baby would be managed (nursery, pediatric floor, etc.). A good resource for this information is Bridget Allen, RN, the Neonatal Outreach Education Liaison (beeper # 0562) or the Attending Neonatologist.
3. Next, the Resident or NNP should determine if the patient’s (e.g., parent’s) managed care plan will provide reimbursement for the back transport and care at the other facility (the social worker can provide invaluable assistance with this determination). Final approval of the decision about back transport should be obtained from the Attending Neonatologist, and only then should a discussion about possible back transport be brought up with the parents. Once these factors have been determined and the parents have approved the back transport, the NNP or Resident should plan a date for the transport with involvement of the following people:
• Receiving hospital physician
• GHS Attending Neonatologist
• Patient’s parents
• Primary NICU physician or NNP
• Primary NICU nurse
• Transport team
4. The Resident or NNP should prepare a transfer summary note. The receiving physician and hospital should be notified and updated again prior to transport (particularly if several days have lapsed since arrangement began or if the patient’s management has changed).
Preparation of the paperwork may seem tedious, but please remember how frustrating it is to get incomplete paperwork with an infant referred from an outside hospital. One of these days, you may be on the receiving end!
Reference Reading List
(1) Ramanathan R, Corwin MJ, Hunt CE, Lister G, Tinsley LR, Baird T et al. Cardiorespiratory events recorded on home monitors: Comparison of healthy infants with those at increased risk for SIDS. JAMA 2001; 285(17):2199-2207.
(2) Ip S, Chung M, Kulig J, O'Brien R, Sege R, Glicken S et al. An Evidence-Based Review of Important Issues Concerning Neonatal Hyperbilirubinemia. Pediatrics 2004; 114(1):e130-e153.
(3) Clark R, Powers R, White R, Bloom B, Sanchez P, Benjamin DK, Jr. Prevention and treatment of nosocomial sepsis in the NICU. J Perinatol 2004; 24(7):446-453.
(4) Clark R, Powers R, White R, Bloom B, Sanchez P, Benjamin DK, Jr. Nosocomial infection in the NICU: a medical complication or unavoidable problem? J Perinatol 2004; 24(6):382-388.
(5) Clark RH, Wagner CL, Merritt RJ, Bloom BT, Neu J, Young TE et al. Nutrition in the neonatal intensive care unit: how do we reduce the incidence of extrauterine growth restriction? J Perinatol 2003; 23(4):337-344.
(6) Clark RH, Gerstmann DR, Jobe AH, Moffitt ST, Slutsky AS, Yoder BA. Lung injury in neonates: causes, strategies for prevention, and long-term consequences. J Pediatr 2001; 139(4):478-486.
(7) Kinsella JP, Abman SH. Inhaled nitric oxide: current and future uses in neonates. Semin Perinatol 2000; 24(6):387-395.
(8) Carter BS, Leuthner SR. Decision making in the NICU--strategies, statistics, and "satisficing". Bioethics Forum 2002; 18(3-4):7-15.
(9) Catlin A, Carter B. Creation of a neonatal end-of-life palliative care protocol. J Perinatol 2002; 22(3):184-195.
(10) Bloom BT, Mulligan J, Arnold C, Ellis S, Moffitt S, Rivera A et al. Improving growth of very low birth weight infants in the first 28 days. Pediatrics 2003; 112(1 Pt 1):8-14.
(11) Walker MW, Shoemaker M, Riddle K, Crane MM, Clark R. Clinical process improvement: reduction of pneumothorax and mortality in high-risk preterm infants. J Perinatol 2002; 22(8):641-645.
(12) Horbar JD, Carpenter JH, Buzas J, Soll RF, Suresh G, Bracken MB et al. Timing of initial surfactant treatment for infants 23 to 29 weeks' gestation: is routine practice evidence based? Pediatrics 2004; 113(6):1593-1602.
(13) Horbar JD, Carpenter JH, Buzas J, Soll RF, Suresh G, Bracken MB et al. Collaborative quality improvement to promote evidence based surfactant for preterm infants: a cluster randomised trial. BMJ 2004; 329(7473):1004.
(14) Rogowski JA, Staiger DO, Horbar JD. Variations in the quality of care for very-low-birthweight infants: implications for policy: two approaches hold promise for improving U.S. infant mortality rates, which are among the highest in the industrialized world. Health Aff (Millwood ) 2004; 23(5):88-97.
(15) Horbar JD, Plsek PE, Leahy K. NIC/Q 2000: establishing habits for improvement in neonatal intensive care units. Pediatrics 2003; 111(4 Pt 2):e397-e410.
(16) Kilbride HW, Wirtschafter DD, Powers RJ, Sheehan MB. Implementation of evidence-based potentially better practices to decrease nosocomial infections. Pediatrics 2003; 111(4 Pt 2):e519-e533.
(17) Sharek PJ, Baker R, Litman F, Kaempf J, Burch K, Schwarz E et al. Evaluation and development of potentially better practices to prevent chronic lung disease and reduce lung injury in neonates. Pediatrics 2003; 111(4 Pt 2):e426-e431.
(18) Ip S, Chung M, Kulig J, O'Brien R, Sege R, Glicken S et al. An Evidence-Based Review of Important Issues Concerning Neonatal Hyperbilirubinemia. Pediatrics 2004; 114(1):e130-e153.
(19) Baker CJ, Kanto WP, Jr. Implementing new GBS guidelines requires coordinated care. AAP News 2003; 22(2):79-86.
(20) ACOG Committee Opinion. ACOG Committee Opinion: number 279, December 2002. Prevention of early-onset group B streptococcal disease in newborns. Obstet Gynecol 2002; 100(6):1405-1412.
(21) AAP. Apnea, sudden infant death syndrome, and home monitoring. Pediatrics 2003; 111(4 Pt 1):914-917.
(22) Saari TN. Advisory Committee on Immunization Practices, the American Academy of Pediatrics and the American Academy of Family Physicians. www.cdc.gov/nip/acip. Jan. 2006.
(23) Section on Ophthamology, AAP, American Academy of Ophthamology and American Association for Pediatric Ophthamology and Strabismus. Screening Examination of Premature Infants for Retinopathy of Prematurity. Pediatrics 2006; 117: 572-576
NEONATAL SERVICES
I. NEWBORN INTENSIVE CARE UNIT (NICU)
A. The Children’s Hospital NICU of the Greenville Hospital System (GHS) functions as a regional Level III (tertiary care) referral intensive care nursery for approximately 14,000 births per year from a six-county area in upstate South Carolina. All direct patient care will be provided and organized by the Resident Housestaff and by the GHS neonatal nurse practitioner (NNP) staff under the supervision and direction of the Attending staff. In other instances, infants may be admitted to the NICU under the direction of the Pediatric Surgery service or a primary-care pediatrician.
B. Our NICU is currently a licensed 80-bed facility on the 6th floor of the Children’s Hospital. It has recently expanded resulting in NICU I and NICU II. There are 37 designated Intensive/Intermediate care beds in NICU I, 16 Intermediate/Intensive care beds in NICU II as well as 17 level II beds for late preterm and term infants with clinical problems that cannot be managed in the Newborn Nursery and a Family Learning Center consisting of 10 rooms in NICU II where parents may stay for one or more nights to learn the care of their soon-to-be discharged infant.
C. On average, there are 750 - 950 admissions per year to our NICU. Eighty-five percent (85%) of our admissions are inborn patients. The survival rate over the past 4 years has been > 95% for all admissions (realizing that more premature infants and critically ill term infants may be at increased risk for mortality).
E. Data on birth weight and gestational age specific mortality are available at:
http://www.pediatrix.com/workfiles/clinicalresearch/EGA_BW.pdf
http://www.pediatrix.com/workfiles/clinicalresearch/WO_Morbidity.pdf
https://www1.nichd.nih.gov/epbo-calculator/Pages/epbo_case.aspx
II. RESIDENT PHYSICIAN LEARNING OBJECTIVES AND RESPONSIBILITIES
A. Objectives: By the end of the third year (or three NICU rotations), the Pediatric Resident should feel comfortable and knowledgeable with the following procedures and newborn disease processes:
1. Core Procedures
a. Evaluation and stabilization of the term newborn infant in the delivery room.
b. Evaluation and stabilization of the preterm infant in the delivery room.
c. Confidence and ability to coordinate and run a neonatal code resuscitation.
d. Ability to properly intubate any infant in respiratory distress.
e. Ability to properly intubate an infant who requires aspiration of meconium or installation of artificial surfactant.
f. Ability to properly insert an umbilical venous (UV) or arterial (UA) catheter.
g. Ability to properly perform and interpret a neonatal lumbar puncture.
h. Ability to properly perform a needle aspiration and chest tube insertion for an infant with a tension or otherwise compromising pneumothorax.
i. Ability to appropriately order and interpret routine neonatal chest and abdominal X-rays.
j. Ability to properly screen and/or treat an infant at risk for sepsis.
2. Knowledge
a. General Perinatal Medicine
The learner should:
• Gain knowledge and understanding of perinatal risk factors, including factors predisposing to preterm delivery and maternal risk factors affecting the fetus.
• Be able to review the specific maternal risks associated with early teen pregnancy and pregnancy after age 35, multiple gestational pregnancies, diabetes in pregnancy, hypertension in pregnancy, hydrops in pregnancy, erythroblastosis fetalis, and perinatal infections.
• Be able to discuss fetal physiology and perinatal monitoring techniques and maternal and fetal laboratory testing.
• Be able to identify the risks associated with delivery of infants including breech deliveries, shoulder dystocias, use of mechanical assistance devices, and Caesarean section.
b. General Neonatal Care
The learner should:
• Possess knowledge and understanding of basic neonatal care requirements for term and preterm infants including temperature regulation, basic free water requirements, basic electrolyte requirements, mineral needs, and caloric requirements.
• Be able to order and manage enteral and parenteral nutrition for any neonate.
• Have a general understanding of the normal vital sign ranges for all types of infants in an NICU setting and understand normal neonatal thermal regulation.
• Understand general radiological principles and how to interpret basic neonatal chest and abdominal X-rays.
c. Central Nervous System Knowledge
The learner should:
• Possess knowledge and understanding of basic embryological brain development.
• Be familiar with the following pathological conditions:
-- Intraventricular hemorrhage (IVH)
-- Periventricular leukomalacia (PVL)
-- Other acute brain vascular accidents
-- Hypoxic-ischemic encephalopathy (HIE)
-- Seizures in the newborn
-- Hydrocephalus
-- Perinatal and newborn central nervous system (CNS) infections
-- Congenital brain malformations
-- Congenital neuromuscular disorders
-- Meningomyelocele
and understand evaluation techniques and treatment options for each of these diseases (including imaging techniques such as MRI, CUS, and cranial CT.
• Understand risk factors associated with subsequent development of cerebral palsy and/or mental retardation and the importance of neonatal developmental follow-up.
d. Respiratory System Knowledge
The learner should:
• Understand and develop management plans for infants with:
-- Respiratory distress syndrome (RDS)
-- Transient tachypnea of the newborn
-- Pneumonia
-- Aspiration syndromes
-- Bronchopulmonary dysplasia, BPD
-- Pneumothorax
• Understand the embryology and management of congenital malformations of the lung, including:
-- Diaphragmatic hernia and other lung hypoplasias
-- Cystic adenomatoid malformation
-- Congenital emphysema and other cystic malformations
-- Tracheoesophageal fistulae
-- Alveolar capillary dysplasias
• Understand the physiology of pulmonary surfactant systems and the clinical utilization of artificial surfactants.
• Understand the risks for and management options for persistent pulmonary hypertension of the newborn (PPHN).
• Understand upper airway complications.
• Have a good understanding of the basic ventilators and ventilator strategies employed in our NICU.
• Know how to properly interpret blood gases, oxygen saturations, and transcutaneous pCO2 measurements.
• Understand surfactant uses and normal pulmonary function values for the preterm and term infant.
• Understand the differential diagnosis associated with apnea of prematurity and the management strategies for neonatal apnea.
e. Cardiovascular System Knowledge
The learner should:
• Understand basic cardiac embryology.
• Understand normal and abnormal neonatal cardiovascular hemodynamics.
• Understand basic cyanotic and non-cyanotic congenital heart disease and how to medically manage individual cases both acutely and chronically.
• Be able to calculate intravenous drips of vasopressors or vasodilators.
• Understand common neonatal arrhythmias, how to interpret electrocardiograms (EKGs), and the use of drugs or other interventions to manage arrhythmias.
• Understand who is at risk for persistent patent ductus arteriosus (PDA) and the risk and treatment of this problem.
• Appreciate the difference between common neonatal murmurs.
f. Blood and Hematopoietic System Knowledge
The learner should understand:
• Common neonatal hematopoietic disorders, including:
-- Anemia
-- Thrombocytopenia
-- Neutropenia
-- Coagulopathy
• More rare complications associated with polycythemia, thrombocytosis, and neutrophilia.
• The proper preparation and ordering of blood products for the neonate.
• Graft-versus-host disease in the neonate.
g. Immune System Knowledge
The learner should understand:
• Common perinatal infections and how to evaluate and manage them.
• Early-onset sepsis and nosocomial infections in the neonate.
• Antibiotic, antiviral and antifungal regimens and dosing in the neonate.
• Risks associated with vertical and horizontal transmission of disease in the neonate.
• The evaluation and management of the “rule-out sepsis infant.”
h. Gastrointestinal (GI) Tract and Liver Disease Knowledge
The learner should understand:
• Basic gastrointestinal developmental embryology.
• Common neonatal GI pathology, including:
-- Malrotation
-- Volvulus
-- Omphalocele
-- Gastroschisis
-- TE fistulas
-- Atresias
-- Hirschprung’s disease
-- Gastroesophageal reflux (GER)
-- Meconium ileus
• Risk factors and management strategies for necrotizing enterocolitis (NEC).
• Management of the infant with short bowel syndromes.
• The evaluation and management strategies for the infant with elevated indirect and/or direct hyperbilirubinemia.
• Basic congenital liver diseases.
i. Renal System Knowledge
The learner should:
• Understand basic renal embryology.
• Understand common developmental abnormalities, including:
-- Hypospadias
-- Posterior urethral valves
-- Ureteropelvic junction (UPJ) and ureterovesicular junction UVJ obstructions
-- Hydronephrosis
-- Parenchymal malformations
• Appreciate the genetic risks of recurrence.
• Understand basic urine output requirements for neonates and disorders in urine electrolytes and renal function tests.
• Understand syndrome of inappropriate secretion of antidiuretic hormone (SIADH) and diabetes insipidus in the neonate.
• Understand renal dosing requirements for neonatal drugs.
j. Other Organ System Knowledge
The learner should understand:
• Basic endocrine function of the neonate, including thyroid function and disorders of calcium, phosphorus and magnesium.
• Management of the infant with hyperinsulinemia.
• How to manage an infant on an insulin drip.
• Common skin disorders and proper skin care for the neonate.
• Basic eye diseases, including cataracts, congenital glaucoma, and retinopathy of prematurity (ROP).
• Common neonatal orthopedic disorders.
• Common neonatal genetic syndromes and chromosomal disorders.
• Basic acid-base physiology and common congenital metabolic disorders and how to evaluate for and manage them.
Diagnostic Testing (NICU)
The learner should understand:
• Indications for, limitations of, and interpretation of common diagnostic and imaging studies used in the NICU. Know gestational age appropriate normal laboratory ranges. Understand cost and utilization issues.
• Diagnostic test properties including use of sensitivity, specificity, positive predictive value, negative predictive value, likelihood ratios, odds ratios and relative and absolute risk.
• Common maternal screening labs including HIV status, RPR or VDRL results, blood type and antibody screening, CF screening results, AFP results, maternal drug screening results and fetal lung maturity results.
• Common X-rays obtained in the NICU to assess ET placement, PICC line placement, UAC and UVC placement. Know when to order X-rays, ECHOs, MRIs, ultrasounds, etc.
• Common NICU blood tests including CBC with differential, blood chemistries, blood glucose, renal and liver function tests, C-reactive protein, drug concentration monitoring, serological tests for infection, coagulation studies, blood gas tests, urinalysis, CSF analysis, gram stains, stool studies, state newborn metabolic screening
Procedural and Therapeutic Modality Competencies (NICU)
The learner should understand:
• Common monitoring and therapeutic modalities used in the NICU including oximetry, apnea monitoring, cardiorespiratory monitoring, inhaled nitric oxide, ventilatory support options (high flow nasal cannula, CPAP, conventional ventilation and HFOV), and pCO2 monitoring.
• Common use and skills in providing Neonatal resuscitation in the delivery room, intubation, umbilical line placement, peripheral arterial puncture techniques, needle aspiration of the thorax and abdomen, chest tube insertion, suprapubic stick, lumbar puncture.
• Common use of home medical equipment including oxygen, apnea monitoring, G-tube equipment, tracheostomy equipment, home ventilators and home hyperalimentation. Be able to provide support and education for use of maternal breast pump use.
m. Ethics in the NICU
The learner should understand:
• Common ethical dilemmas in the NICU and how best to resolve these events.
• Parental rights laws.
• The importance of and develop plans for obtaining informed parental consent.
• That the delivery room is never the ideal place for acute decisions to be made about whether an infant is non-viable or not. A resident should never be solely responsible for these decisions. To quote from Norman Fost in Fanaroff and Martin’s 7th Edition of Neonatal-Perinatal Medicine (2001), “... the usual recommendation is to stabilize all live born infants and then to transfer them to the intensive care unit where they can be fully assessed. If the infant is truly non-viable, or if it is not in the child’s interest to be maintained, there will nearly always be some life-sustaining treatment that can be discontinued.”
B. Specific Daily Responsibilities for the PL-1 Pediatric Resident (also includes Family Practice Residents or Transitional Year Residents)
1. This individual will be the primary care physician for patients in the NICU. This physician will be expected to evaluate his/her patients, develop clinical management plans, and implement these plans under the guidance of the PL-2 or PL-3, NNPs and Attending Neonatologists. These responsibilities include:
a. Completing an admission note on EPIC as soon as possible after admission.
b. Entering at least one progress note per patient per day.
c. Writing procedure notes for umbilical line placement, intubation, lumbar puncture, etc. Each procedure note should be accompanied by a statement acknowledging that parents were informed of details related to any non-emergent procedure and that they have given consent for this procedure.
d. Presenting patients at morning rounds to the Attending Neonatologist(s). Presentations should be concise. Organization of the presentation should follow the flow sheet at the patient’s bedside. An example:
1. Patient’s name, post-menstrual age, and the number of days after birth
2. Patient’s current weight and gain (loss) from previous day
3. Previous day’s vital signs, including fluid intake (mL/kg/day) and urine output (mL/kg/hour)
4. Number and type of apnea and bradycardia events
5. Discussion by problem (should be individualized for each patient, (e.g., there is no need to discuss every system in an otherwise stable infant). Specifics included should highlight any system failure or improvement, pertinent lab values, medications needed and plan for the day. Problems that are often discussed are listed below:
-- RDS/BPD
-- Nutrition Assessment
-- Apnea of Prematurity
-- Actue Renal Failure
-- Jaundice
-- Sepsis
-- Anemia
-- Other (e.g., social)
f. Writing all orders and informing bedside RN or respiratory therapist (RT) that an order has been written.
g. Performing all procedures as appropriate and with supervision as needed.
h. Communicating with parents frequently by phone and/or at bedside (attempt daily communication with your most critically ill patients and at least 2 times per week for intermediate patients).
i. Discharge and social planning - discussing each admission as soon as possible with the NICU social worker. Discharge planning should be planned as far in advance as possible with the Attending Neonatologist, Social Worker, and the patient’s primary nurse. PL-1 residents will need to contact (talk to) all follow-up physicians prior to discharge, Kathy Gentry discharge coordinator can also assist with arranging outpatient follow-up.
j. Performing check-out rounds that will start in the afternoon (4:00 - 4:30). Once all routine daily responsibilities are completed and notes written, a plan for overnight management should be formulated. This plan should be discussed among the neonatologist and the resident or NNP on call.
k. Other specific patient responsibilities include:
-- PL-1s may have up to 8 patients on their weekday clinical service. These numbers will vary depending on census (i.e., if the census gets very high, your patient load may increase) and NNP/other resident coverage. The patients carried by the PL-1 will usually be more stable infants.
-- On weekdays, preliminary rounds should be performed on each of your primary patients before morning rounds, which start at approximately 9:30. Typically, this will mean that you must arrive by 7:00 am.
-- Weekend service typically requires the PL-1 or NNP on call to round on the majority of the intensive patients as their primary responsibility (patient load may be up to 15 patients). Rounds begin at the same time as weekdays, but because weekend responsibilities require you to know about most of the sicker infants (who may not be your responsibility during the week), you may have to arrive earlier in order to be ready for rounds.
-- A resident may leave the NICU early (i.e., when they are post call or for other Resident designated responsibilities), provided that sign-outs to the remaining resident or NNP are complete and appropriate.
-- During the first month of a first-year resident’s duty, the resident’s goals should be to:
• Become thoroughly oriented to the NICU
• Be able to perform a physical exam and assessment of the neonate
• Gain increased understanding of basic pathophysiology of neonates
• Participate in delivery room resuscitation/stabilization of high-risk neonates
• Perform procedures (e.g., intubation, umbilical catheter placement)
• Attend cesarean births with supervision
• Learn neonatal nutritional needs (e.g., parenteral and enteral feeding regimens)
• Identify problems and develop care plans, including long- and short-term goals for each problem
• Participate in discharge planning for your patients
• Serve as the primary medical communicator about your patients with parents/referring physicians.
-- Night back-up: Emergencies should be immediately communicated to the Attending in-house physician. Anticipation of a high-risk delivery requiring Neonatology support should be relayed to the Neonatologist on call ASAP. Other concerns or questions about patient management should be communicated to the Neonatologist on call without hesitation.
-- Absence from rotation: Any elective absence from a scheduled NICU rotation must be approved by both Dr. Grisham (or Dr. Kolarik for Med-Peds Residents) and Dr. Halliday or Dr. Ruggieri. Some of these absences may require the PL-1 to obtain resident cross-coverage from their colleagues in order for the PL-1 to leave the NICU rotation. Extended absences beyond a few days may also require the PL-1 to make up the lost time on subsequent rotations
Finally, three additional pertinent caveats to remember are:
(1) Never antagonize the NNPs, RTs, nurses, Social Workers, ward secretaries, or laboratory technicians (these are your friends, support system and allies)!
(2) Don’t make disparaging (pessimistic) comments about patients - especially in front of parents!
(3) Appreciate the medico-legal importance of maintaining patient confidentiality!
Our NICU is a close-knit group of people who have worked hard to make this an outstanding neonatal unit. They also are a group who, for better or worse, will relay a negative experience about a resident to other members of the team perhaps subjecting a resident to a bias he or she doesn’t deserve. If you are experiencing personality conflicts (and they will happen on occasion), be tactful and pursue grievances through the appropriate channels:
Routine day-to day nursing issues should be addressed with the daily charge nurse. Other NICU personnel include:
• Head Nurse Manager: Karen Merritt, RN, MBA, BSN, AAB
• NNP coordinator: Deborah Lynch, MSN, NNP-BC
• NICU Respiratory Therapist Clinical Supervisor: Suze Westmoreland, RRT
• Laboratory Technician Supervisor: Karen Greene, MT
• Attending Neonatologist Liaison: Matt Halliday, MD; Jeffrey Ruggieri, MD (however, don’t hesitate to express your immediate concerns with the Attending Neonatologist on service)
C. Responsibilities for the PL-2 or PL-3 Pediatric Resident
1. Acts as a preceptor for first-year residents (e.g., attends deliveries, helps with procedures, helps with order writing, helps in writing daily notes, coordinates discharge planning). These requirements will be limited for the post-call PL-2 or PL-3 (e.g., an NNP or Attending will assist the PL-1).
2. Attends Attending/resident rounds, as well as other scheduled rounds. The PL-2/3 should also accompany the Attending Neonatologist to parent conferences (antenatal and postnatal) as time permits.
3. Carries a patient load consisting of 8-10 infants. The PL-2/3 will remain responsible for all admissions that occur on his or her day on call (including delivery attendance, performing procedures, writing orders and admission notes, and developing a post-call treatment plan.
4. PL-2/3 residents are strongly encouraged to begin to review the pertinent neonatal literature emphasizing an evidence-based medicine approach where applicable. Short presentations of pertinent topics and literature reviews will merit “bonus consideration” based on their quality. Any PL-2/3 who demonstrates an aptitude in this area will merit consideration for an “excellent” rotation evaluation score.
III. ALLIED HEALTH CARE PERSONNEL AND PROGRAMS
A. Neonatal Nurse Practitioners: These individuals have had additional specialized training (many have their Masters degree) and have passed a nationally administered certifying test in high-risk neonatal care. They are very skilled in resuscitation and NICU procedural skills. They also have an outstanding knowledge base. Their function in our NICU is to assist the Neonatologists with the daily assessment and plan of care for selected infants on their team (the other infants being the responsibility of the residents). They are also part of our education team and can assist in answering Resident questions and concerns.
• Coordinator: Tyner Lollis
-- Deborah Lynch
-- Charlene Wells
-- Treasure Snyder
-- Dawn Allen
-- Catherine Wilson
-- Karen Covington
-- Ara Messemer
-- Kyle Weir
-- Jamie Bott
-- Melissa Dunham
• Nurse Manager : Karen Meritt, RN, MBA, BSN, AAB
• Nursing Supervisors:………………………………Ashley Childress, RN, Dana Batty, RN, Nancy Satterfield, RN, Monica Kates, RN
Adjunct Nurse Educator for orientation Carol Whitten, RN
• Clinical Nurse Specialist (nurse educator): Susan Chamberlain, RN
• Head Transport Nurse: Mary Sansbury, RN
-- Each infant is assigned to a primary nurse within 48 hours of admission.
-- He/she will plan 24 hour nursing care, maintain contact with family and plan for discharge.
-- It is essential that residents coordinate care with this nurse.
-- Primary nurses should be invited to parent conferences.
-- Each shift has a charge nurse who will facilitate nursing attendance and input at rounds.
-- Bedside nurses are assigned for 12 hour shifts and are responsible for care and observations and alerting doctors to subtle or obvious changes.
C. Pediatric Respiratory Care (the NICU Respiratory Therapy Shift Coordinators are Amanda Egli, RRT, Jonathan Miller, RRT, Brian New, RRT, and Jon Johnson, RRT
1. Our respiratory therapy group is comprised of nationally certified individuals, often with several years experience in neonatal respiratory care. They provide 24-hour coverage, 7 days a week in the NICU. Their responsibilities include:
a. Evaluation of respiratory equipment for safety, consistency, efficiency and effectiveness. They are responsible for set-up, monitoring and maintenance of all oxygen delivery and ventilatory assistance devices.
b. Performing ordered ventilatory adjustments and recommending changes in equipment and therapy when needed.
c. Assessing patient’s respiratory status (breath sounds, arterial blood gases (ABGs), etc.) and effectiveness of therapy.
d. Assisting with the development of respiratory care policy and procedure
e. Performing intubations as needed for credentialing or in emergent situations
f. Assisting with and/or performing special studies related to respiratory care including drawing of arterial blood gases from umbilical arterial catheters (UACs) and peripheral arterial lines.
g. Facilitating communication among therapists, medical technologists, nurses and physicians.
h. Developing and assisting in management of respiratory care protocols and research projects (such as our ventilatory weaning protocol for all infants on conventional ventilatory support).
2. Always notify the therapist in cases of respiratory emergencies, intubations or extubations in order to ensure appropriate assistance.
3. Always notify respiratory therapist when a respiratory order is written. The respiratory care orders are on a clipboard at the bedside (not in the blue chart).
D. NICU Laboratory Medical Technologists
1. These individuals are trained and certified and provide around-the-clock coverage, 7 days a week. Their duties include:
a. Obtaining and processing all blood specimens on all lab tests ordered with the exception of blood cultures (obtained by the bedside nurse, resident, or NNP) and arterial blood gases (obtained by RT or attending physician).
b. NICU laboratory evaluation includes: blood gas analysis, electrolytes, bilirubin, glucose and hematocrit.
c. Delivering NICU and main lab results to the patient’s bedside.
d. Calibrating, maintaining and performing quality assurance on all lab equipment.
2. Communication System
a. The house staff and NNPs are responsible for writing all lab orders, including routine labs (glucose and hematocrit), which are determined by the “status” of the patient, e.g., “high-risk” vs. “low-risk”. STAT orders will be processed as soon as they are collected; otherwise all labs are obtained with the morning blood draws.
b. Time-specific lab values (medication levels) must be ordered to be drawn at a certain time.
c. Lab orders should specify frequency and/or specific times for lab work to be drawn (e.g. Q 12 hrs or M-W-F).
d. Daily lab orders should be reviewed and “discontinued” when no longer appropriate.
e. Lab techs are not allowed to take verbal orders from the patient care staff.
f. Occasionally, the laboratory staff will need back-up help. Examples include an inability to obtain a sufficient quantity of blood or if a NICU laboratory analysis machine fails (getting it up and running is a top priority in their job description).
E. Social Services
1. Two social workers are assigned to the Mother-Baby Unit of the Greenville Hospital System, currently Whitley Mann, MSW. They should be consulted on every admission and should be re-consulted at least 5-7 days prior to any hospital discharge or transfer (whenever possible). They are responsible for placing a family evaluation on the chart within a few days of admission. This reference provides valuable social information and phone numbers where family members can be contacted. The social workers should be kept abreast of any relevant social/parental concerns and should help coordinate and attend any parent conference. They will also be responsible for any physician ordered home equipment arrangements and/or home nursing requirements. At night or on weekends, there is also a social worker on call 24 hours a day for pediatrics.
Pharmacy
Bethany Lynch, Pharm D is the clinical pharmacist for the NICU. She rounds on
patients with the team and adds valuable input regarding the management of medications in the NICU including levels, weaning medications, medication protocols, etc.
G. Nutrition
Billy Watkins is the Dietician dedicated to the NICU exclusively.
IV. NICU DAILY ROUTINES
A. Orders
1. Current order sheets (except for respiratory orders) and patient charts are kept at the patient bedside. All orders require the patient name and weight to be on the order sheet. All medications, intravenous feedings (IVFs), TPN, feeding, laboratories, consults, specialty requests (e.g., chest X-ray (CXR), echocardiogram (ECHO), cranial ultrasound (U/S)), blood product transfusions, and change in care status orders are written in this chart in black ink (photocopies much better than any other color). Please designate as STAT (to be performed in < 1 hour) those orders that must be performed immediately and notify the patient’s nurse.
2. All medication orders must be written as milligrams or micrograms per kilogram per dose (or micrograms/kg/min) whenever applicable.
3. Ventilator, oxygen and respiratory treatment orders are written in the neonatal ventilator order.
4. TPN orders prepared by the pharmacy must be entered by 12:00.
5. No verbal orders are permitted, except in emergencies and these must be signed ASAP.
B. Rounds
1. There are 3 separate attending Neonatologists for the Resident and NNP teams. Additionally, there is usually a Delivery Room Attending who assists with deliveries, consultations and admissions during the weekdays.
2. Attending rounds are held seven days a week in intensive beginning at approximately 9:30 on weekdays and between 9:00 - 10:00 am on weekends. Residents and NNPs should have already pre-rounded on their patients and be prepared to present them.
3. We will attempt to hold teaching rounds (for everyone) in the early morning or late afternoon on 3 weekdays per week. This is usually a short discussion of a clinically relevant topic.
Rounds should not be interrupted except for emergency situations. To help avoid interruptions, the Delivery Room attending will assist with acutely deteriorating infants, attend deliveries and tend to admissions to preserve the morning rounds.
V. CLINICAL PROTOCOLS RELEVANT TO PREMATURE INFANTS (See "Protocols" Tab for complete details: regarding these protocols).
CRANIAL ULTRASOUNDS for all infants < 31 weeks’ estimated gestational age (EGA) or < 1500 grams birth weight (and other selected patients)
EYE EXAMS TO EVALUATE FOR THE PRESENCE OF RETINOPATHY OF PREMATURITY (ROP) OR OTHER DISEASES OF THE EYE. For all infants < 1500 grams birth weight and/or < 31 weeks gestational age (and other selected infants).
AUDIOLOGY EXAM for all infants prior to discharge.
BLOOD TRANSFUSION PROTOCOL
Because transfusion of blood products is a sensitive issue for parents, a handout (handouts are also available for a host of other procedures and therapies) has been prepared and should be given to all parents upon admission of their infant to the NICU. It discusses risks/benefits of blood transfusions in a fashion that is easily understood by the average lay person. All infants must have a blood sample for type and cross-match (minimum 1 cc) sent to the GHS blood bank prior to any blood product transfusion.
VI. SPECIAL PROCEDURES
A. Stable infants leaving the NICU must be accompanied by an NICU nurse.
B. Unstable infants must be accompanied by a nurse and a physician (a member of the transport team may be an acceptable alternative in selected instances).
C. Notify nursing 24 hours ahead of schedule, when possible.
D. If not possible, notify nursing as soon as the decision to do procedure is made.
VII. DELIVERY ATTENDANCE
Delivery attendance is requested by Labor and Delivery (L&D) in selected cases. Medium-risk deliveries may be attended by a PL-2/3 (after the first month’s rotation) without additional assistance. Please make note of equipment needs in L&D or the C-section suites and report any deficiencies to the L&D charge nurse immediately. The Resident should be aware that they may request assistance by the NICU resuscitation team (see below) for any delivery. High-risk deliveries are attended by the NICU resuscitation team, which consists of a Resident or NNP, an NICU nurse, and an RT. An attending Neonatologist will also attend any high-risk delivery.
VIII. ADMISSIONS, IN-HOSPITAL TRANSFERS & TRANSPORTS
A. All incoming phone calls about possible transports should be referred to the Delivery Room Attending (or night call) Neonatologist. A special transport form is available at the front desk (usually found in a Transport Notebook at the Front Desk). It should be filled in when a phone call is being taken from a referring physician. The charge nurse and the Attending will discuss census problems and/or staffing needs for the transport babies.
B. Back Transports (step-down transports) -- Purpose and Procedure
1. To facilitate parent-infant bonding by shortening distance parents must travel to visit their baby, to lessen hospitalization costs for a convalescing child who no longer needs intensive care, and to fully utilize the regional system of perinatal care.
2. In order to optimize back transports, the Resident or NNP should find out if the receiving hospital has the staff and technical capability to manage this infant, what the visitation policy for the parents will be, and where this baby would be managed (nursery, pediatric floor, etc.). A good resource for this information is Bridget Allen, RN, the Neonatal Outreach Education Liaison (beeper # 0562) or the Attending Neonatologist.
3. Next, the Resident or NNP should determine if the patient’s (e.g., parent’s) managed care plan will provide reimbursement for the back transport and care at the other facility (the social worker can provide invaluable assistance with this determination). Final approval of the decision about back transport should be obtained from the Attending Neonatologist, and only then should a discussion about possible back transport be brought up with the parents. Once these factors have been determined and the parents have approved the back transport, the NNP or Resident should plan a date for the transport with involvement of the following people:
• Receiving hospital physician
• GHS Attending Neonatologist
• Patient’s parents
• Primary NICU physician or NNP
• Primary NICU nurse
• Transport team
4. The Resident or NNP should prepare a transfer summary note. The receiving physician and hospital should be notified and updated again prior to transport (particularly if several days have lapsed since arrangement began or if the patient’s management has changed).
Preparation of the paperwork may seem tedious, but please remember how frustrating it is to get incomplete paperwork with an infant referred from an outside hospital. One of these days, you may be on the receiving end!
Reference Reading List
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