Resident Survival Guide to

1. NICU Rotation Resident Survival Guide to

2. My life is in your hands. Please wash your hands!!

3. 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 Infection CONTROL……..

4. 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. Admission Orders

5. 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

6. 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. Some CPOE AND GENERAL NICU tips

7. 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

8. 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

9. 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. MORE CPOE AND GENERAL NICU tips

10. 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. Weekly Lab orders…….

11. 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 . Preparation Rounds

12. 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 Progress Notes

13. 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 NICU Power Notes

14. 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. Discharge Planning

15. 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 • A second screen is repeated 3 days completely off TPN • When the baby is transferred or has died • Prior to giving Blood products • Repeat screening is performed 90 days post transfusion • Follow the algorithm on the NICU-MD drive Newborn State Screen

16. 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 Delivery room attendance

17. 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. Procedures

18. 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. Transfer

19. 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

20. 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 and sign outs

21. 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

22. 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 Conferences/teaching Rounds

23. 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! Last but not Least

24. 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. Nextel communication

25. Hope you have a wonderful rotation!!! Welcome