Transcript NICU Orientation - Stony Brook School of Medicine

RESIDENT SURVIVAL GUIDE TO
NICU Rotation
MY LIFE IS IN YOUR HANDS. PLEASE WASH
YOUR HANDS!!
INFECTION CONTROL……..

Please review the scrubbing video on the NICU MD drive
 Please scrub for approximately 3 minutes before starting patient care.

Remove rings, jewelry and watches.

Please wash hands before and after each patient contact.

Blue charts and monitors are patient contact areas please make sure you wash
hands when you use them

Pay attention to dress code
 Only white coats parachute dress allowed yellow scrubs are no longer permitted.
 Full sleeve sweaters not permitted in OR, only short sleeves are permitted
ADMISSION ORDERS

Admissions

Admission
 CPOE
 CPOE admission orders are found under neonatal admission
power plan.

Before any initial order, you must first go to ad hoc charting and
add a patients weight and allergy history.

History: please attempt to get a complete antenatal history with a
date of the Hepatitis BsAg test result (as now required on every
admission), delivery history.
Physical examination: do as complete exam as is possible at time
of admission. Some parts may be deferred. Also perform a
modified Ballard Exam on admission when possible.

SOME CPOE AND GENERAL NICU TIPS

All babies admitted to the NICU from L&D should receive antimicrobial
eye prophylaxis (erythromycin eye ointment 0.5% in both eyes X 1) and
Vitamin K IM 1mg/0.5ml for all babies (found in the NICU admission
power plan)

Available Consents: NICU Admission, Elective immunizations, HIPAA,
Exchange transfusion and circumcision consents exist for the NICU and
must be completed if the patient’s condition warrants. Consents must
be in the preferred language of the mother if we have them (Spanish)
and a medical translator (via telephone) must be used and it should be
documented in the chart when used. Consents must be obtained from
the mother, or the father when they are legally married.

Parents are welcomed to be in the NICU with their baby soon after
admission. The HCW (RNs and docs) determine the timing for this.
SOME CPOE AND GENERAL NICU TIPS

We have several power plans in place; examples include


Neonatal Admission power plan
Neonatal Antimicrobial Power plan


When ordering antimicrobials for a patient (not newly admitted because the
admission power plan has these) there is a neonatal antimicrobial power
plan. Click on the dosing chart to find the correct dosage and frequency.
Neonatal eye exam power plan for ROP

Every baby who is scheduled to have an eye exam (according to AAP
guidelines) is to have this power plan ordered.
 All eye exams are on weekly (Wednesday).
 The list of babies who are to have eye exams is distributed the day
prior
 The power plan orders for the eye exam expire in 24 hours and should
be ordered in the afternoon prior to the scheduled exam for
administration at the specific time to you by the designated eye nurse.
MORE CPOE AND GENERAL NICU TIPS

When ordering morning labs and xrays, you must change the date to tomorrow’s and
make the time for 0001 and STAT if lab and urgent for xrays.

We have many NICU-specific orders. To find them type in either “NICU” or “neonatal”
in keywords and change search to “Contains”.

CPOE has been a challenging undertaking in the NICU, we will help you with any
order you must enter. Please do ask us for help.

There are no verbal orders in the NICU, unless it is an emergency, “Check Back
Required”

All orders including ventilator and IV fluid rate changes should be placed in the
computer and communication with the nurse or RT is essential.

The list of CPOE NICU-specific guidelines are found on the NICU-MD drive.
MORE CPOE AND GENERAL NICU TIPS

Please avoid remote orders; for example placing orders in the call room. This
breeches communication between the physician and nursing staff, which places our
patients in jeopardy. Orders should be placed at the bedside with the nurse
whenever possible.

Medication Orders

Use the “comments” section of the orders to designate the dosing weight you
are using for the ordered medication. When possible, please write the source of
the drug, its concentration and calculation in the comment section

Birth weight is used for the first 7 days of life, then the dosing weight is taken
weekly unless otherwise specified

Use the preprinted sheets for drips, and the caloric goals and protein content of
the formula’s on laminated sheets in the rooms. You can also find this
information in the NICU-MD drive
MORE CPOE AND GENERAL NICU TIPS

When you believe a consult is needed, you must first discuss it with the fellow or
attending.

Apnea consults must be called to 4-3783 because there is not connection between
an ordered consult in Cerner and notification of the request by the consultant. Direct
communication is best.
WEEKLY LAB ORDERS…….

Weekly blood draws are ordered on Monday for Tuesday morning.
 Usually we will have a standing weekly order for HC and length. Our weekly order
for labs will often include hemoglobin, Hematocrit, Retic count, medication
levels, and LFT’s. X-rays should be ordered weekly for babies with a central line.

We review all medications weekly as an evaluation for the continued need of the
drug and to increase the dosage based upon weight gain over the past week. Order
rewrites are done on Thursdays before noon


When rewriting medication orders, please ask the nurse for the time of next dose to continue the drug
on its regular schedule, for example caffeine is given at noon. Allow pharmacy at least 2 hours
preparation time to dispense a newly updated medication dose.
On Wednesday (resident lecture day), please come in early and round, order daily
medication drips if needed and give a proper and through sign out to the covering
resident.
PREPARATION ROUNDS

Daily rounds



Attend Daily Brief 7.00-7.10
Sign outs 7.10-7.45
Attending and Fellow rounds start at 8.00
 Examine the sickest and vented babies first. Evaluate for significant PDA, for
quality of breath sounds, for laterality of sounds, tender abdomen, and
make observations.

Review all X-rays and labs. Calculate all I/O’s based upon today’s weight (all
fluids, intakes and vitals are in CPOE under the I&O tab).

You will be expected to formulate a TPN order plan for your baby (if needed)
and then to discuss with the fellow .
PROGRESS NOTES

Daily progress notes






Residents are required to write daily progress notes during weekdays and
weekends.
Number limited to 4 notes.(includes admission and discharge/transfer notes)
Patients will be assigned by the attending physician
All patients should have a growth charts charted during weekly measurements.
There should be a event note(SBAR) on all patients
when there are any changes made to existing plan(
change is status, post op notes..)
Residents are required to write a off service notes at
the end of rotation
NICU POWER NOTES

Templates






NICU encounter………….Admission folder
NICU Progress notes……..progress notes folder
Pediatric SBAR………..Event folder
Free Text Note can be used for interim /focus notes stored
in a Event or a Progress folder depending on the note.
All notes must be endorsed to Attending Physician
NICU procedures are still in paper forms due to need
for universal time out and nursing signature
DISCHARGE PLANNING

Discharge planning rounds is a multidisciplinary meeting with the medical
team, social worker, discharge coordinator, speech, clergy and NICU
ophthalmology nurse.

During these rounds we discuss all the discharge planning, social, medical
and ethical issues to help expedite a patient’s timely discharge

Held every Tuesday at 3:00pm

The pediatric ophthalmologist will follow his patient’s every single
Wednesday and if the baby is discharged on a Monday, the “weekly” follow
up appointment will most definitely be in 2 days, Wednesday.
NEWBORN STATE SCREEN

On admission every baby gets a metabolic and newborn hearing screen
ordered.

Collect the metabolic screening at 3-5 days of life on full enterel feedings

A specimen must be drawn before this optimal time for these conditions:
 Prior to initiating TPN



When the baby is transferred or has died
Prior to giving Blood products


A second screen is repeated 3 days completely off TPN
Repeat screening is performed 90 days post transfusion
Follow the algorithm on the NICU-MD drive
DELIVERY ROOM ATTENDANCE





All resident are required to attend cesarean sections, with a fellow or NNP at least 3
times before they become certified to attend routine repeat cesarean sections alone.
All residents will undergo Clinical Skill Training in the Skill Lab to review basic NRP
and PPV application as a part of credentialing process to attend Level 1 deliveries ,
during the first week NICU rotation.
Residents are required to participate in all deliveries with back up from Attending /
or NICU fellow or NNP (review DR attendance guidelines sheet)
If there are any unforeseen incidents in L&D, contact the NNP, fellow, attending STAT
by phone or Baby-Baby phone.
Please Proactively ESCALATE any situations you are concerned about, un settled, or
feel is a safety issue you come across to a fellow, attending or NNP
PROCEDURES

We encourage the residents to do procedures. All LIPs in the NICU must be certified
to perform a NICU procedure before performing it independently. You may be
supervised by either a fellow, attending or NNP for most any procedure.

All procedure notes are preprinted and have a mandatory time out. Completely fill
out the form for each procedure done; include the number of attempts ,whether it
failed or succeeded, who participated, complications and findings.
TRANSFER

If a patient is to be transferred to newborn nursery or an outside facility, the resident
must:
 Examine the patient, write transfer orders, a transfer note and notify covering
resident in NB nursery before the baby is transferred.
 Complete transfer order template on the Cerner prior to transfer.
 NICU fellow to call PMD or service attending for every transfers.
 Residents and NNP to call NBN resident for all transfers.
 Clean up all orders on CPOE that pertain to NICU history and not for newborn
nursery BEFORE transfer.
ON CALL AND SIGN OUTS

The on call resident should be at the fellows’ and attending s’ sign out at 4:00pm for
all patients both Red and Green Teams.

The on call resident is expected to have a detailed sign out for each of the resident
baby’s from their colleagues.

They are expected to manage all the resident babies along with the fellow.

The are expected to carry the L&D phone and attend as many deliveries as possible,
often with the fellow or NNP.

They are expected to present updates on lightning rounds at 9:00pm with the fellow,
NNP, and charge nurse

They are responsible for the checking labs, x-rays , and updating the fellows with
results and changes during the night
ON CALL AND SIGN OUTS

The resident is expected to formulate a plan before calling the fellow

The resident is expected to call for help when not sure what to do. They are
expected to bump up the question to the attending if they are still uneasy with the
answer from the fellow or NNP.

The residents are not expected to be neonatologists and know everything about
neonatology. But you are expected to read and present neonatal cases and issues
during the rotation. You are expected to make mistakes when you answer questions.

Residents are expected to speak with the patients’ parents but may need help from
the attending or fellow for more sensitive or delicate issues.
ON CALL CONT.













Criteria for Residents to Call Fellows
All x-rays
All blood gases
All critical test results and critical lab
values
Bilirubin level requiring phototherapy
Sodium less than 132 and more than 145
Glucose less than 50 more than 150
Potassium less than 3.5 more than 6
Calcium less than 8 more than 11
Deviations from the blood pressure
protocol
All consults to well-baby nursery
Any feeding problems/abdominal
distension
New medication orders









Criteria for Residents to Call Fellows
Temperature instability
Transfusions
Any increase in FI02 greater than 10%
over baseline.
Significant, increasing or persistent
apnea for bradycardia.
Infants requiring positive pressure
ventilation.
Arrhythmias
Loss of IV access
Problems with any central line
Residents should also call if they need any sort of help
CONFERENCES/TEACHING ROUNDS

One NICU Morning Report in 025 at 8.30 am
 This is a monthly conference held in the Pediatric conference room,
 Resident will be assigned a case to present and review the case at the morning
report.

Attending /Fellow Teaching Rounds Tuesdays and Thursdays 1400-1500
 Weekly meeting held in the NICU conference room,
 Residents will be assigned to read a Article on Specific Neonatal Topics and review
and discuss on teaching rounds

Daily bedside teaching rounds

Divisional Academic Conferences ( optional but residents are welcome to attend) at Noon
in NICU conference room
LAST BUT NOT LEAST

Remember even though the NICU is split into a red and green team, we are really
just one team!
 Please work together, help each other and value everyone's input.
 If you see something wrong, say something!

Please notify the fellow, NNP or attending with any changes that have happened
during the day or night

Remember everything at first seems hard and confusing; do not get discouraged.

If you have any questions please ask a fellow, NNP or attending.

When people are working together, the NICU will run smoothly and is a great place to
work.
You are a valued member of the NICU team! Our future is with you!

NEXTEL COMMUNICATION
Resident 1 and resident 2 phones are assigned
to the group.
 Kindly use R-1 phone during on call hours.
 Required to carry them and respond to DR
calls.
 Charge them when not in use, additional
batteries are available at the front desk.

WELCOME
Hope you have a wonderful
rotation!!!