Intern Survival Guide

1. Intern Survival Guide Newborn Nursery

2. Introduction Schedules Where things are When things happen Pre-rounding: Newborn Exam Admissions Progress Notes Discharges Orders Transfers to/from NICU Attending Rounds Family Rounds Important People Medical Students Weekend Call Outline

3. So you’re starting the newborn nursery… • The newborn nursery is located in the new mother-baby ward of the hospital. To get there, hang a right at Starbucks and take the elevator to the 6th floor. You’ll need your ID at practically every entrance so don’t forget it! • The nursery itself is located about halfway down the hallway. The front door is on the north side (higher numbers); the door closest to where the resident hangs out is on the south side (lower numbers). Only the south entrance requires your ID to let you in. • When the census is low, most moms (and babies) reside on the 6th floor. There is, however, overflow to the 5th floor (usually antepartum), so pay attention to where your patients actually are. • Dress code is business attire ± white coat. If you’re on over the weekend, you may wear scrubs.

4. Schedules • As the newborn resident, you’ll be working from whenever you arrive in the morning (more on that later) until 5pm. • You will work one weekend day for three weekends with one golden weekend. • To check the Newborn schedule, go to New Innovations  Scheduling Assignment  Monthly Schedule 

5. Schedule Access To access your personal schedule, go to: New Innovations: https://rms1.newinnov.com/Login/Login.aspx After logging in, hit View: Take a couple of hours one day and just browse through new innovations. It does take some getting used to.

6. Where Things Are: Babies and Accessories Babies themselves will either be in the nursery or in with their moms. If you need to examine a baby and the baby is not in the nursery, the easiest thing to do is to go into the mom’s room and examine the baby there. You can also bring the baby back to the nursery with you or (very nicely!) ask the floor nurse to bring the baby to you. Bassinettes are stocked with pretty much everything you need: diapers, wipes, receiving blankets, etc. Ophthalmoscopes are located here and there around the two nurseries for easy access.

7. Where Things Are: Charts Blue Baby Charts Located in the nursery during the early morning hours and out on their appropriate floors after rounds. Things you will find in the charts that are important to you, in order from front to back: NBN report sheet – when the nurse from L&D delivers the baby to the nursery, the newborn nurse takes notes on this sheet. Provides a summary of information. Inpatient Admitting Face Sheet – with insurance information Assessments/H&P section NB nursery summary sheet – the infamous “columns” sheet in duplicate. Serves as your history, admission and discharge physicals. Admission/Delivery Summary – usually put in the day after admission, details information printed from the CIS system. Birth Report (sometimes) Physician Orders – where discharge orders are written. Consents – HepB and circumcision. Progress Notes Report of Operation – Birth report will be found here if not in the H&P section Nursing Records – NICU/NBN nursing admission sheet

8. Where Things Are: Charts Red Mom Charts Located in L&D with mom immediately after delivery. Comes over with mom when she is taken to her room. There are 2 things in this chart important to you: Prenatal Records – usually clipped to the front of the chart or in the H&P sections Admission Note – in the H&P section. Will provide a wealth of information, including the number of antenatal visits. HIV, GBS, HepB and blood type will be written in a number of places. RPR and DAT are usually done when the mom is admitted, so check mom’s Powerchart for those.

9. Where Things Are: Charts Yellow Bedside Charts Clipped to the baby’s bassinette. Record of: Day of life Birth weight Daily weight and change  Tip: Nurses weigh the babies at 5pm each night. If the new day’s flow sheet is missing a weight, check the flow sheet from the day before. It’s often recorded in a column there. Vital signs Voids and stools Feedings NAS scoring (if applicable)

10. Where Things Are: Paperwork Blank Flow Sheets/Progress Notes Newborn nursery is a lot of paperwork. Paperwork has its place in medical education - not only does it keep you on top of what is going on with your patient, but you learn the very important skill of proper documentation and time-management. You will find most necessary documentation in the filing cabinet near the resident’s table. From top to bottom: Growth charts Admission/Progress flow sheets Newborn Admission Note* Progress notes Bilirubin curves Attending flow sheets* Resident Binder Big, black binder that houses flow sheets in three sections (in order of priority): Discharges New patients Interim patients *attending-only paperwork

11. When Things Happen

12. Pre-Rounding • Your arrival time each day to the nursery should be based upon how many patients are on your census (at our busiest, we can get up to 25-30), how comfortable you are with the paperwork and how well you can manage your time. In general: • If you are the only person in the nursery or your medical students are very new, you should arrive between 5:30am – 6:00am. • If you have seasoned medical students or are lucky enough to have another MD in the nursery with you (another intern or a family medicine resident), you should get here between 6:00am and 6:30am, 7am at the latest. • The first thing you should do when you hit the nursery is scrub, surgical style, at one of the sinks. Stay on the good side of the nurses. Trust us. • Next, print two copies of the census (hit task  print  print) from PowerChart. One is for you, one is for the attending. Take a big, black marker and cross off any babies who aren’t staff (see next slide).

13. Hospitalists Maribeth Chitkara Rachel Boykan Carolyn Milana Lisa Wilks-Gallo Clinic Attendings Tech Park Robyn Blair Leslie Quinn Lycia Ryder Taranjeet Ahuja East Moriches Susan Walker Tracy Down Rosa Cataldo More Clinics Patchogue Cathy Coleman Fred Reindl Robyn Labarca Islip Liliana Tique Southhold Nancy Pearson Riverhead Ann Hansen Staff Babies

14. Pre-Rounding • Note on your census which babies need to be admitted, which ones you think should be discharged and which ones are interim. • An anticipated discharge list (with total and direct bili levels) will be hanging up on a clipboard to your right as you walk in. • Compare the anticipated discharges with patients you think should be discharged home (day 2 NSVD, day 3 CS). Anyone missing from the anticipated list could still be discharged. Check with the floor nurses – or better yet, moms themselves – to find out. • Organize yourself using your census as a to-do list. (Appendix 1) • Examine all of the babies, discharges with priority. •  Tip: If the census is manageable, see all the babies in the nursery first. Then, take your black binder and ophthalmoscope out onto the floor and see the babies in their mothers’ rooms. • If the census is crazy, ask the nurses very nicely if you could please have, at the very least, the discharges brought to you. • The night newborn resident should have done all of the admissions overnight, but you should still examine all of the new babies in the morning if you have time to do so (especially if they were admitted before midnight). • Before or after your exam, note on your flow sheet the date, DOL, weight, change from birth weight, feeds, voids, stools and physical exam.

15. The Newborn Exam • Nose • Check for patency by placing one finger on one nare and listening for air on the other. • Mouth • Check for cleft palate and suck reflex by placing gloved finger in the mouth and feeling for the palate. • Look for Epstein Pearls (white lesions) • Uvula – normal versus bifid • Symmetry when crying • Neck • Supple? • Feel for nodes or masses • Check clavicles by feeling for fractures/ crepitus • Lungs • CTAB good aeration vs otherwise • Heart • Listen with bell • RRR, nl S1 and S2, any murmurs? Good pulses? Cyanosis? • Abdomen • Softness • Diastesis rectus (gap where rectus muscles should be) with hernia? • Bowel sounds present? • Any masses or HSM? Feel for liver edge. • Cord: 3 vessels by exam or report • The Newborn Exam: • General Appearance: alert, active, NAD • Skin • Look at color – pink, cyanotic, acrocyanotic • Feel for temperature – is baby cold, or warm • Look for any rashes • Nevi (red, brown, blue), stork bites on back of neck… • Look for Mongolian spots • Nails • Are nails short or long • Are they stained with meconium • Head • Feel for fontanelles • Feel for caput succedaneum – crosses sutures • Feel for cephalohematoma – does not cross sutures • Look for any bruising, stork bites, nevi • Look for molding • Eyes • Check for red reflex • Look for red nevi on eyelids • Look for conjunctival hemorrhage • Look for cataracts by placing light from the side • Look for any discharge from the eye – conjunctivitis? • Ears • Look for patency • Look for any tags

16. The Newborn Exam • Genitalia • Male • Circumcision? • Scrotal sacs for descended testes • Patency of anus • Female • Check labia • Check for any vaginal tags • Patency of anus • Extremities/Back • Check for symmetry • Feel for any lymph nodes under armpits • Check for hip dislocation: • Ortolani: Grab knee, placing 4th and 5th fingers on hips, then external rotation (O = OUT) • Barlow: Grab knee and press back down with fingers in the same position. (B = BACK) • Check for hip laxity • Turn the baby over and check for: • Tufts of hair • Angle and symmetry of spine • Dimpling • Brachial/Femoral pulses • Neurologic • Tone: Lift baby from under the arms - does baby slip between your fingers? • Check for all 4 reflexes: grasp, suck, moro, and rooting • Check for tremors

17. Pre-Rounding Paperwork: • After examining all of the babies, gather all of the charts and sit down to get all of your paperwork done, discharges again with priority. • The night newborn resident should have done all overnight admissions, but make sure all of the information on your flow sheet and summary sheet is complete. • The following slides will detail the necessary paperwork for admissions, discharges and interim patients.

18. Admissions • To keep on top of admissions, refresh your census frequently, keep your ears open for calls from L&D and listen for the printer (it will print lots of pages with new admits). • When the baby first gets here, listen to the L&D nurse sign-out to the nursery nurse. If you miss it, don’t worry. All the initial information goes on the first sheet in the chart, the Newborn Nursery Report Sheet. • Double check which pediatrician is written on the green Newborn Physician Information sheet that comes with the baby. If it’s not staff, it’s not your admission, no matter what the computer says. If it is, roll on. • The nurse will take the baby to the warmer and do her admission. Let her chart everything and bathe the baby. Her vitals and physical will go in the Nursing Records section. Once the chart is complete and the baby is nice and clean, you can start your admission. • Comb the chart for all the information necessary to fill out your admission flow sheet. Remember, maternal RPR and DAT will be in the computer. • Do your exam and fill the PE section. • Transcribe all of the information you have onto the blank Newborn Admission Summary Sheet found in the H&P section. Don’t forget to put the HIV and GBS status down by PNLs.

19. Admissions (Continued) • Admission Orders • Some orders will be put in by the L&D nurse. • Your admission orders will be found in your pediatric folder under “Newborn Nursery Admission Power Plan.” Everything will be checked for you (except for social work/lacatation consults). Initiate and sign. • Mom’s Arrival • As you might have noticed, some things are missing from your admit flow sheet/summary sheet. All of those things will be neatly filled in once mom arrives at postpartum. • Mom will give consent/refuse HepB • Mom’s chart is a wealth of information: • Her medical history • Her prenatal labs • Notifying the Attending • Unless you are unsure about a plan of action, there is no need to notify an attending about an admission. • The attendings will see the new babies during evening rounds or the next morning. • The H&P and exam must be filled out within 24 hours of birth time.

20. The Interim Babies • For babies that are neither coming nor going, fill out the back of the admission/interim flow sheet for that day. • Grab a blank “NP/MD” progress note and fill it out. • The attending will co-sign your note and/or write her own. • Because the attending must write a note on all of the interim babies, they are last on your priority list. If there is a huge number on the census and you don’t get to them, don’t worry.

21. Discharges • Discharges are the number one priority in the morning. Double-check the anticipated discharge list and see everyone. • Fill out the discharge weight, date and time of discharge exam and the discharge columns on the summary sheet. Don’t forget: • Date and hour of life of T/D bili (drawn the night before at 4am), written in the lower left box • Recording any labs done • Anything else that you would want to know if you were the primary pediatrician • Fill out the discharge orders (located in the “physician orders” section of the baby’s chart). Note the date and time of their follow-up appointment and what the baby should be feeding. • After the attending sees the patient and gives his or her blessing, write discharge orders on PowerChart.

22. Transfers to/from NICU • Transfers to NICU can be done at any time. • If you are especially worried about a baby, take the baby over first, then talk to someone. • This is true of notifying the attending, as well. • Always go with the baby if they are transferred to NICU. • When you get there, sign-out to the resident (and fellow, if necessary). • If you just want the baby looked at and assessed by a NICU fellow, have one paged. • As with any transfer, make sure to write a detailed transfer note. • Transfers from NICU • Babies admitted with gestations 34-35 wks may be transferred to NBN after 24hrs of cardio-respiratory monitoring.   • Infants > 35 weeks may go up anytime after determined to be stable. • Newborns with any type of physiologic instability/delayed transition may be transferred to NBN after consultation with the accepting physician. • Transfer Orders from NICU should include the name of physician accepting transfer and any orders that should be continued, i.e., feeding, medications, etc. • On admission to Newborn, fill out the H&P admission column. Gather all the information that you would with any other admission.

23. Orders • All order writing is now done electronically through our CPOE system. Please refer to your PowerChart training for more specific instructions. • You should notify the patient’s nurse of any new orders, especially if the order is written as STAT. •  Tips and Tricks • Admission orders are found in the “pediatric” folder. The “Newborn Nursery Admission Power Plan” will have everything you need to admit a baby. • If HepB was given, it should be found under the baby’s MAR. • To find out if the mom was given appropriate antibiotics, check her MAR. • If you have a withdrawal baby on morphine and it is time for a dose change, remember that the pharmacy sometimes takes forever and a day to get drugs where they need to be. • If you are going from .12mg to .09mg Q4H, and the baby is due to receive a .12mg dose at 8am, let the baby get it. • After the baby receives that dose, cancel the order in PowerChart and put in the new dose (.09mg), first dose to be given at 12pm. • Make sure to call the pharmacy and let them know you’ve made this change. You should get the new dose in time for the 12pm administration, but no promises.

24. Attending Rounds • Attending rounds are generally bedside, incorporating presentations with teaching. • Usually begin at around 9:30am, though this is attending dependent. • Each attending will let you know their rounding preferences and their expectations of you and your medical students. • Length of rounds is obviously dependent on the census. When the census ranges from 10-15, you will likely be done by noon. This gives you plenty of time for lunch, new admissions and afternoon mommy rounds.

25. Mommy rounds • In the afternoon, you and your medical students should make rounds to see all of the families on the floor. • General questions to ask: • Do they have any questions or concerns? • Breast/bottle feeding? Any problems with breastfeeding? • Who will be the baby’s pediatrician? If they do not have one, are they interested in one of our clinic pediatricians? • Who is the insurance provider for the baby? (Make sure we take their insurance if they want one of our doctors!) • Note the patient’s PMD and insurance on your admission flow sheet. • Address any and all concerns the parents have. Reassure them that there is a pediatrician on at all times and their baby will be looked at every day.

26. Anticipatory Guidance • Rectal thermometers only in first 2 months of life. • Any temperature below 97 or above 100.4 is an emergency. • Back to Sleep (SIDS campaign). • Baby sleeps alone in the crib on his/her back, no pillows or stuffed animals, reducing the risk of SIDS. • Carseats • Parents must have one before leaving the hospital • Current AAP recommendations as of April 2009 are to be rear-facing until age 2 or outgrows manufacturer’s limits for weight and height. • Smoking • Address any other concerns the family may have, ie immunizations, jaundice, etc. • Note that you’ve given anticipatory guidance somewhere on your flow sheet.

27. Important People • Lisa Clark (beeper 4-5859) • Newborn Nurse Practitioner • Lisa helps to “run” the nursery by assisting the team with any number of tasks. She spends considerable amount of time with the many psychosocial issues we have in the nursery. • It should not be assumed by any member of the newborn team that Lisa will be available to assist with morning rounds or pre-rounding work. • Lisa has 25 years of newborn experience and is also our resident neonatal withdrawal expert. If you don’t know something, chances are, Lisa does. She is an invaluable resource. • Kathy Vanderventer – lactation consultant • Darlene/Stephanie – social workers

28. Medical Students • All students assigned are to collect information, examine and chart on infants. • Depending on the ability to complete tasks, the average assignment is 3-5 patients. • Medical students should also assist with new afternoon admissions. • All assigned patients are under the supervision of the residents and nursery attending. All findings admission/ discharge chart notes must be completed in time to attend AM rounds. • It can get busy, but try to make the time that the students spend in the nursery worthwhile. Teach as much as you can, even if it’s only pearls of wisdom here and there. They’ll appreciate it.

29. Assignments • www.Breastfeedingbasics.org • Click “Register”, then click “Students enroll in your course”. Then type in Stony Brook and click “Find”. Then register and complete the course. (You may skip the International Section.) • The scores of this course will be sent to Dr. Guralnick. • Newborn Nursery Exam • https://ezexam.som.sunysb.edu/q4/perception.dll • As part of your newborn nursery rotation, all interns must take and pass the online exam that is now available.  All the questions are based on the required readings on pedsportal.   • The test will contain approximately 13 random questions from a large bank of board style questions.  If you do not achieve 85% or better, you will need to retake the exam until you pass.  You will not pass the rotation if you do not pass the exam.   • You will need an access code that will only work for a limited period of time after your rotation ends, therefore it is critical that you take the exam in a timely fashion during the last week of your rotation.  • Please e-mail or see Elaine for your individual access code.  • Schedule time to observe a Lactation Consultant interact with a mother/baby. • Observe one hearing evaluation. • Perform an observed physical exam.

30. Required Readings • Week 1: • Hypoglycemia protocol • Clinical Practice Guideline Management of GBS in the Neonates • Summary sheet on Hepatitis B, Hepatitis C, HIV, Syphillis, and TB • Week 2: • Neonatal Jaundice • Respiratory Disorders of the Newborn • TORCH infections • Hepatitis B • Week 3: • Presentation of Congenital Heart Disease in the Neonate and Young Infant • Fetal Hydronephrosis • Development Hip Dysplasia • Week 4: • Brachial Plexus Injury • Sudden Infant Death Syndrome • Newborn Hearing Screen

31. Weekend Call • Weekends are structured exactly like weekdays. Time your arrival depending on the census, and take into consideration that neither Lisa nor the medical students are available over the weekend. • Most attendings will get in early, see babies by themselves, then sit down to round. (However, this is extremely attending-dependent, so stay flexible!) Make sure that you have all your paperwork done. •  Try to get all clinic appointments scheduled on Friday and Saturday. Clinics are closed on Sundays.

32. Appendix 1 • How you organize yourself is up to you, but most interns will use their census as a to-do list.