MEMORANDUM
TO: Resident
FROM: Dave
Fay
RE: NICU
Rotation
Please
review the attached rotation description and rotation evaluation in detail and
particularly focus on the following main points:
·
Responsibility
for all admissions to the NICU except for those only expected to be observed
for a short while until stable (although I would encourage you to still become
involved in these newborns as time allows).
·
As
much as possible attend all deliveries occurring during the day on weekdays to
become comfortable with quickly assessing and stabilizing newborns of all types
·
Attend
all high risk deliveries at other times when on call. In order for you to be consistently notified when this occurs, it is
imperative that you remind the resident on
·
Spend
time in the wellborn nursery to gain expertise in common problems of newborns
and the providing of anticipatory guidance to their parents.
·
Use
documentation cards for all patients in whose care you play a principal role
and procedures in which you are involved.
·
Specifics
of cross-coverage with the residents on inpatient and outpatient peds.
I
would be happy to discuss this rotation in more detail if you have any
questions or concerns now or during the rotation.
Reviewed: 5/25/05 – DLF:lmc
DESCRIPTION OF
ROTATION
ROTATION: Neonatology (NICU) - WMH and
Children’s
PRECEPTORS:
DURATION: One Month
1. GOALS/OBJECTIVES OF THE ROTATION:
a. Perform accurate and rapid neonatal
assessment (i.e. risk, APGAR, gestational age).
b. Develop the diagnostic and therapeutic
skills needed to evaluate and care for well neonates and provide anticipatory
guidance to their parents.
c. Develop and re-enforce skills needed to
resuscitate and stabilize a sick neonate.
d. Learn how to evaluate and treat the
persistently unstable and sick neonate including how to judge the appropriate
circumstances for obtaining consultation from a pediatrician and/or
neonatologist
e. Learn the appropriate circumstances for
arranging transportation of a distressed neonate to a higher level regional
NICU and how to prepare a neonate for transportation.
f. Learn to support parents following
birth of a child with congenital anomalies, birth complications with adverse
outcome, and fetal or neonatal death.
2. EXPECTATIONS:
a. WMH NICU. As your primary area of
responsibility become involved in all admissions to the NICU even if the
neonate is admitted when you are not on call. Admissions do not include
healthy neonates only being observed in the NICU for a short while immediately
after birth. If the admission occurs while you are on call or 7:00 AM to 5:00
PM during a non-holiday weekday do the initial H and P and evaluation as
permitted by the attending physician. On all admissions, work closely with the
attending, and the neonatologist if involved, to determine and implement
ongoing treatment, especially the performance of procedures. Write daily
progress notes except for weekends and holidays when you are not on call.
As
much as possible attend all births, especially C-sections, 7:00 AM to 5:00 PM
on non-holiday weekdays. The only exception is when scheduled in the WFPC or
attending educational or other residency related sessions, you should limit
your involvement to high risk deliveries likely to provide an important
educational experience. When on call at night, weekends, and holidays, attend
all high-risk deliveries and C-sections (see Appendix A). To
facilitate your involvement in these deliveries it is helpful if you frequently
remind the OB floor and the resident on
b. WMH
Wellborn Nursery. To facilitate
learning about the nuances of well newborn care, ask pediatricians and family
physicians to allow you to become involved in the care of their newborns
outside of the NICU. Such patients can often be identified by talking to the
nurses doing postpartum care, or by watching the delivery board on
c. CHW High Risk Developmental Clinic. Residents will be required to attend at
least one clinic at CHW for graduates of their NICU and the WMH NICU. The goals
of this experience are to better understand the long-term needs of patients who
required treatment in the NICU as well as allowing the residents to become
familiar with the workings of a regional NICU.
3. REQUIRED
Required
Reviewing the neonatal resuscitation
course syllabus is the single most effective way to prepare for the rotation.
During the rotation, the resident is expected to read through the NICU Rotation
Article Syllabus available from Lisa Cerletty. In addition, the neonatologists
will provide you with the latest copy of their Management of Infants in the
Neonatal Intensive Care Unit: Guidelines. Both the syllabus and the
guidelines provide a nice starting point for discussing important neonatal
topics with the attendings as well as being excellent references.
Recommended Texts
As time permits review of the following
texts, which can also be used as references, would be helpful:
. The
Lange Clinical Manual of Neonatology (1992) by T. C. Gomella, M.D.
(strongly recommended reference; a copy is in the NICU for resident use).
. Atlas
of Procedures in Neonatology (1993) by Mary Ann Fletcher and Mhairi G.
MacDonald (a copy is in the NICU for resident use)
. Care
of the High-Risk Neonate (1993) by Drs. Klaus and Fanaroff (a good basic
textbook - available at WMH library).
. Primary
Care of the Newborn (1993) by Seidel, Rotenstein, Pathak (copy in NICU)
. Color
Atlas of the Newborn (1984) by R.D.G. Milner and S.M. Herber (copy in FPC
library)
. Neonatal
- Perinatal Medicine by Drs. Fanaroff and Martin (a more complete text on
the subject - available at WMH library).
4. TYPICAL DAY/WEEK AT THE
a. Non-Holiday
Weekdays. The neonatologists will
typically round at WMH from 8 AM to noon although this may vary with
emergencies and other responsibilities of the neonatologists. You should review the sicker patients and
write notes prior to the arrival of the neonatologist so you can formulate your
own impressions and plans. As much as possible, you should also round with
pediatric or family practice attendings of the NICU patients and the wellborns
with whom you are involved. You should also round on and become involved in the
care of any newborns in the wellborn nursing with interesting findings or with
any problems such as with feeding or hyperbilirubinemia as described above. It
is also important to accompany attendings when they provide anticipatory
guidance to parents. The neonatologists will be available to discuss the care
of all the patients in the NICU even if they are not consulting on that
patient. There is also a series of basic topics listed in the NICU Syllabus for
Family Practice Residents (see attached) that they will discuss with you during
the month, but they are also willing to discuss other topics in neonatology of
interest to you. After rounds are completed, you should remain available for
admissions and newborn resuscitations as described above.
b.
Call weekends and
holidays. On these days, the neonatologist will round at WMH only if there are
patients which require it. You should still attempt to round with the
attendings of all NICU patients and other interesting newborns as well as
wellborns with whom you are involved. On these days, as well as call nights
during the week, you should come in to help resuscitate any potentially
unstable newborns (see Appendix A). You are also responsible for the evaluation
and the formulation of treatment plans for all admissions to the NICU.
5. WORK-UPS/WRITE-UPS:
You are
to perform and document an appropriate H and P on all admissions for which you
are responsible as described above. You are also to write daily notes on NICU
patients, the wellborns on which you are rounding, and patients on the
pediatrics floor as described above.
6. CLINIC PATIENTS IN THE NICU
If a newborn patient
of the family practice clinic remains in the NICU for more than 3 days, the
primary care physician, if a resident, has the option of turning over his or
her role as the rounding physician and coordinator of care to the resident on
NICU (on weekends or holidays when the NICU resident is not on call, or if it
is a month when there is no resident on NICU, then the resident on teaching
service, preferably a PG2 or PG3, will assume care). For all such patients the
faculty member making rounds on the teaching service will supervise care of the
patient in conjunction with any specialists that have been consulted. If the patient has been admitted to the
service of the neonatologists then teaching service resident involvement is
optional. In all cases the PCP is expected to still periodically review
progress of the patient and insure that the needs of the parents and other
psychosocial needs are being met.
7. PROCEDURES:
a. Intubation, suctioning, and bagging.
b. Airway management including the use of
CPAP and the basics of the use of a ventilator.
c. Umbilical catheter placement (venous
and arterial).
d. Peripheral IV's (practice this basic
but important skill as often as possible).
e. Lumbar punctures.
f. Chest tube placement.
g. Treatment of jaundiced neonates
including phototherapy.
h. Obtaining ABG's
i. Newborn exam including gestational age
assessment.
j. Counseling families following birth of
a child with congenital anomalies.
k. Counseling families following fetal or
neonatal death.
l. Performing
anticipatory guidance for parents of newborns.
Be sure to document
all procedures, as well as the principal diagnoses of any patients for whom you
provide medical care, using New Innovations.
8. AVAILABLE
EDUCATIONAL EXPERIENCES:
a. Informal discussions with
neonatologists about interesting current patients, the neonatology topics on
the NICU Syllabus for Family Practice Residents (see attached), and topics of
interest to the resident. Use the nurse practitioner x-ray file to review
abnormal radiographic findings with the neonatologist. It is understood that at
times you may need to miss morning report when rounding with the attendings.
b. Perinatology Conference: This is held
approximately every other month on the 4th Friday of the month at 7:30 a.m. The
purpose of this conference is to discuss one or more cases with educational
elements involving a woman with a complicated pregnancy and delivery, and her
newborn. When held the NICU resident
should attend. The resident may be asked to help to briefly summarize the
significant elements of the care of the newborn(s) presented.
9. IMPACT
ON WFPC SCHEDULE, EDUCATIONAL CONFERENCES, AND OTHER REQUIRED ACTIVITIES:
Residents will be scheduled in the
WFPC the typical number of half-days for their year of training, but only in
the afternoons so this should not interfere with rounds. Residents will be
excused from the WFPC only in the event of an admission to the NICU that
requires immediate attention. Residents will be expected to attend the
Wednesday afternoon educational conferences unless attending the resuscitation
of an unstable neonate or performing other emergency neonatal procedures. As
much as possible the resident should attempt to attend other educational
conferences, but it is understood that at times these may have to be missed
when they interfere with rounding with the neonatologist. The resident is
responsible for attending a high risk developmental clinic at CHW. They are
scheduled twice a month.
10. CALL:
The resident must complete 7 call days
during the block. Flexibility is recommended, in order to maximize experience.
In other words, if a certain non-call day has better potential, call may be
shifted by the resident, and other calls adjusted accordingly. Make sure to
document all call changes.
11.
VACATION/TIME AWAY:
Five
weekdays of vacation are allowed.
12. EVALUATION:
The MCW
neonatologist assigned to WMH for the month of the resident’s rotation will
have primary responsibility. These preceptors should use the designated
evaluation form for this rotation (see attached copy). Please discuss your
performance with your preceptors periodically during the rotation, and let the
curriculum coordinator, Lisa Cerletty, know which wellborn preceptor should
receive an evaluation form.
13. CRITERIA FOR SUCCESSFUL COMPLETION OF
THE ROTATION:
a.
Written evaluation using the designated evaluation form
for the rotation from the MCW neonatologist indicating that the resident has
actively participated in the responsibilities listed above and in the
evaluation form and has not demonstrated any significant deficits in knowledge
or performance.
b.
Completion of all call days and rotation responsibilities
as defined above.
c.
During the rotation the resident will be expected to
successfully perform a simulated neonatal megacode. Arrange with NNP or the
Neonatologist on service at the beginning of the rotation; it is expected this
will result in NRP certification.
d.
Residents will be required to attend at least one CHW
high risk developmental clinic held on Wednesday mornings at CHW for graduates
of their NICU and the WMH NICU.
14. SUPERVISION:
The
resident will be under the supervision of the neonatologist rounding at the
NICU and the attendings of the neonates in whose care the resident is
participating. The resident should remain in close contact with these
supervising physicians whenever formulating treatment plans or rendering care
to the involved neonates. Dr. Fay has ultimate responsibility for coordinating
the rotation.
15. STRENGTHS:
If you
are aggressive, this rotation should offer you multiple opportunities to
sharpen and reinforce your skills in neonatal resuscitation and stabilization. Make sure you document all the patients
that you attend and the procedures you perform, even simple stabilizations of
healthy newborns. With the
opportunity to interact with local pediatricians and family physicians, you
should be able to develop a clearer concept of what basic skills you should
have and when to ask for consultation. The location at WMH should also allow
you a degree of freedom and the chance to develop confidence in your abilities.
The neonatologists rounding at WMH should have ample time to teach, and you
should be aggressive in requesting this.
16. WEAKNESSES:
The
number of unstable and sick neonates varies greatly, and this may impact on
your experience. If the census in the
NICU is low, this can be compensated for by discussing hypothetical case
histories with the neonatologists. You can also become involved in the
well-born neonates and further re-enforce your basic neonatal skills. In
addition, be sure to attend as many deliveries as possible to practice your
resuscitation skills.
DLF:lmc
Revised: 5/25/05
APPENDIX A
GUIDELINES FOR NICU RESIDENT ATTENDANCE AT DELIVERIES
The resident on NICU should be involved in resuscitating
and caring for newborns as outlined below.
1. Non-Holiday Weekdays from
7:00 a.m. to 5:00 p.m.:
a.
The resident should attempt to attend all deliveries to
help resuscitate and care for the neonate.
L
and D should page the resident whenever a delivery is imminent.
b.
When the resident is attending required residency
activities, he should attempt to attend all high
risk deliveries as defined below.
2. Call Nights, Weekends, and
Holidays:
a.
Resident should attend all high-risk deliveries and L and
D should page the resident when such
deliveries are imminent.
b. High-risk
deliveries are defined as:
Gestation
more than or equal to 35 weeks
Multiple
Births
Prolonged
ROM (more than 24 hours)
Presence
of meconium or blood in amniotic fluid
Signs
of Chorioamnionitis
Cesarean
Sections
Fetal
Distress
Any
Known Congenital Anomaly
Known
IUGR
Known
LGA
Any
other situation in which the need for significant neonatal resuscitation is
expected.
Revised: 01/26/98
Reviewed: 05/25/05 – DLF:lmc