Intern Survival Guide: NICU Edition. 2 Outline Introduction Introduction Schedules Schedules Prep...

Intern Intern Survival Survival Guide:Guide:

NICU EditionNICU Edition

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OutlineOutline

IntroductionIntroduction SchedulesSchedules Prep workPrep work Division of laborDivision of labor Where things areWhere things are When things happenWhen things happen Crunching numbersCrunching numbers Rounding with the Rounding with the

attendingattending

IHIIHI OrdersOrders Med RoundingMed Rounding The DR/OR andThe DR/OR and AdmissionsAdmissions Progress notes and Progress notes and

Updating the listUpdating the list DischargesDischarges Signing OutSigning Out CallCall

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So you’re starting So you’re starting NICU…NICU… NICU is located on 8S – hang a right NICU is located on 8S – hang a right

from the elevators.from the elevators. The resident call room is across from The resident call room is across from

the entrance. The code is 145 and the the entrance. The code is 145 and the door sticks. Keep trying. No one door sticks. Keep trying. No one locked you out. We promise.locked you out. We promise.

Scrubs are cool to wear every day, but Scrubs are cool to wear every day, but if you’re wearing long sleeves under if you’re wearing long sleeves under your scrub top, make sure you can your scrub top, make sure you can push them above your elbows easily.push them above your elbows easily.

No eating or drinking at all on the unit. No eating or drinking at all on the unit. There’s a break room to the left when There’s a break room to the left when you walk in and a fridge in the call you walk in and a fridge in the call room.room.

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SchedulingScheduling

If there are only three residents on for the block, If there are only three residents on for the block, you will follow a Q3 schedule. you will follow a Q3 schedule.

If there are four residents on, you can decide If there are four residents on, you can decide amongst yourselves if you want to be Q4 or have amongst yourselves if you want to be Q4 or have a nightfloat week (one week sun night through a nightfloat week (one week sun night through thurs night, plus one additional 24 Friday and 24 thurs night, plus one additional 24 Friday and 24 Saturday). Make sure to e-mail the chiefs in Saturday). Make sure to e-mail the chiefs in advance to let them know.advance to let them know.

There is no scheduled continuity clinic during the There is no scheduled continuity clinic during the NICU month.NICU month.

The resident on call will be the designated “labor The resident on call will be the designated “labor and delivery” person and given the resident and delivery” person and given the resident baby-baby pager each day. That resident is the baby-baby pager each day. That resident is the one who will go to all the deliveries, so stay on one who will go to all the deliveries, so stay on your toes.your toes.

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Schedule AccessSchedule Access

To access your personal schedule, go To access your personal schedule, go to:to:– New Innovations: https://rms1.newinnov.c

om/Login/Login.aspx– After logging in, hit After logging in, hit – View:View:

Take a couple of hours one day and Take a couple of hours one day and just browse through new innovations. just browse through new innovations. It does take some getting used to.It does take some getting used to.

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PreparationPreparation

If it’s July and NICU is your first rotation, If it’s July and NICU is your first rotation, you’ll have a nice orientation during you’ll have a nice orientation during orientation week and you can get sign-orientation week and you can get sign-out from the departing intern then.out from the departing intern then.

If it’s not July, the day before the rotation If it’s not July, the day before the rotation starts, make your way up to the NICU starts, make your way up to the NICU and get sign-out from one of the interns. and get sign-out from one of the interns. If they’re really nice, they’ll show you If they’re really nice, they’ll show you around and teach you how to do around and teach you how to do numbers.numbers.

If not, or if you’re still confused, just If not, or if you’re still confused, just continue reading this presentation.continue reading this presentation.

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Division of LaborDivision of Labor

NICU patients are divided into three teams, NICU patients are divided into three teams, first by color (red and green) and then by first by color (red and green) and then by covering practitioner (resident or NP). There covering practitioner (resident or NP). There is no NP on the red team. is no NP on the red team.

The NNPs are amazing so be really nice to The NNPs are amazing so be really nice to them… I’ve heard they like chocolate.them… I’ve heard they like chocolate.

When you’re on call at night and over the When you’re on call at night and over the weekend, you’re responsible for all the weekend, you’re responsible for all the resident babies, red and green. It’s hard to resident babies, red and green. It’s hard to know all of the opposite team’s patients very know all of the opposite team’s patients very well, since you don’t round on them daily, well, since you don’t round on them daily, but try to pay close attention to the history but try to pay close attention to the history and management of the patients on your and management of the patients on your own team, even if they’re technically not own team, even if they’re technically not “your patients.” It really helps.“your patients.” It really helps.

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Where Things Are: Where Things Are: The BindersThe Binders The big yellow The big yellow (red team)(red team) and blue and blue (green (green

team)team) binders will be your team’s filing binders will be your team’s filing cabinet. cabinet.

Here is an overview of what’s inside:Here is an overview of what’s inside:– Yellow binder only: Yellow binder only:

Rounding information Rounding information Tips, tricks and Suzanne’s “So you’re starting NICU” Tips, tricks and Suzanne’s “So you’re starting NICU”

document, also posted on fellinahole document, also posted on fellinahole Dictation templateDictation template

– Blank daily flowsheets and progress notesBlank daily flowsheets and progress notes– Admission face sheets and H&P (for admission and Admission face sheets and H&P (for admission and

discharge) formsdischarge) forms– Ballard scoring (front) with growth curves (back)Ballard scoring (front) with growth curves (back)– Current patient information separated neatly by Current patient information separated neatly by

handmade dividers (using sticker pages).handmade dividers (using sticker pages).– Recently discharged patient information – we keep Recently discharged patient information – we keep

them for a few days.them for a few days.

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Where Things Are: Where Things Are: Bedside ChartsBedside Charts There are a couple things that are important There are a couple things that are important

to you in the thin, blue bedside chart:to you in the thin, blue bedside chart:– Apnea/Brady log (usually right at the front.)Apnea/Brady log (usually right at the front.)– IHI (we’ll get back to this later)IHI (we’ll get back to this later)

If you take a bedside chart out of a room, tell If you take a bedside chart out of a room, tell the nurse. Even better, ask that nurse if he the nurse. Even better, ask that nurse if he or she minds that you take it. They’ll or she minds that you take it. They’ll appreciate the consideration.appreciate the consideration.

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Where Things Are: Big Where Things Are: Big Red ChartsRed Charts The big red charts sit behind the clerk. The big red charts sit behind the clerk.

Things that will there that are important to Things that will there that are important to you:you:– Progress notesProgress notes– ConsultsConsults– Admission paperwork (after it’s done)Admission paperwork (after it’s done)– DR/OR summary (in the OR section)DR/OR summary (in the OR section)– Outside institution/lab informationOutside institution/lab information

All charts are All charts are thinnedthinned once a week. Old once a week. Old charts can be found in the big filing cabinets charts can be found in the big filing cabinets where the printer is, behind the clerk’s desk.where the printer is, behind the clerk’s desk.

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Where Things Are: Where Things Are: ConsentsConsents

Mom is the consenting parental unit Mom is the consenting parental unit alwaysalways unless there is unless there is a CPS issue. Dad can never give consent.a CPS issue. Dad can never give consent.

There are a bunch you should get when the baby is first There are a bunch you should get when the baby is first admitted:admitted:– NICUNICU – give permission to be in the NICU – give permission to be in the NICU– JHACOJHACO – acknowledges we gave her info on privacy – acknowledges we gave her info on privacy– HepBHepB – if baby is >2kg. – if baby is >2kg. – CircCirc – if mom is interested. – if mom is interested.

They will either be clipped in the blue chart (usually when They will either be clipped in the blue chart (usually when patient is first admitted) or in the “consent” section of the patient is first admitted) or in the “consent” section of the red chart. If the consents are in neither of those places, red chart. If the consents are in neither of those places, just ask the clerk to print them out for you. just ask the clerk to print them out for you.

If you don’t get the consents right away, it’s fine. Moms If you don’t get the consents right away, it’s fine. Moms will usually visit when they recover, before they make the will usually visit when they recover, before they make the cross-country trek to mother-baby. If they don’t, just grab cross-country trek to mother-baby. If they don’t, just grab the forms and head over to L&D. Moms will want to know the forms and head over to L&D. Moms will want to know about what’s going on anyway, so it’s good chance to about what’s going on anyway, so it’s good chance to update them/ask questions/get consents signed.update them/ask questions/get consents signed.

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Where Things Are: Where Things Are: Daily Sign-OutDaily Sign-Out

The first computer right as you walk in is The first computer right as you walk in is our resident computer. Here you can our resident computer. Here you can find the hard drive with the sign-outs… find the hard drive with the sign-outs… but only if you have access.but only if you have access.

Make sure to e-mail Peter Vecere and Make sure to e-mail Peter Vecere and ask him for UHMC Peds Access. This will ask him for UHMC Peds Access. This will give you access to floor sign-outs, too.give you access to floor sign-outs, too.

The pediatrics drive is on the desktop. The pediatrics drive is on the desktop. The most recent sign-out will be in the The most recent sign-out will be in the “NICU” folder.“NICU” folder.

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Where Things Are: Where Things Are: MiscMisc

Optho BookOptho Book – On top of the cabinet that – On top of the cabinet that houses the green team red charts.houses the green team red charts.

Extra stickersExtra stickers– Big Red ChartsBig Red Charts– Thin Blue ChartsThin Blue Charts– ““Red” or “Green” (literally labeled as such) clerk’s Red” or “Green” (literally labeled as such) clerk’s

binder, usually on the inside left corner of the desk.binder, usually on the inside left corner of the desk.– In the large reservoir of what clerks can print for In the large reservoir of what clerks can print for

you. I’ve heard they like chocolate.you. I’ve heard they like chocolate. LinensLinens – To the left, on the way out of the – To the left, on the way out of the

NICU by room 114.NICU by room 114. Med roomMed room – code is 2001. – code is 2001. OphthalmoscopeOphthalmoscope – Usually in the med room. – Usually in the med room. Vaccine Information SheetsVaccine Information Sheets (VIS) – Lower (VIS) – Lower

right desk drawer in front of room 112.right desk drawer in front of room 112.

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When Things HappenWhen Things Happen

Weekly Labs (H&H, retic) – Order on Weekly Labs (H&H, retic) – Order on TuesdayTuesday for for AM WednesdayAM Wednesday

Weekly length, head circumferenceWeekly length, head circumference– Order on Order on TuesdayTuesday for for AM WednesdayAM Wednesday – Don’t forget to plot these!Don’t forget to plot these!

Optho exams – Optho exams – WednesdayWednesday Fluid, drip, TPN renewal – Fluid, drip, TPN renewal – Every dayEvery day

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When Things Happen - When Things Happen - TPNTPN

TPN must be ordered before 11 every TPN must be ordered before 11 every day.day.

Fellows like to order TPN before rounding, Fellows like to order TPN before rounding, so try to catch them so you can do it so try to catch them so you can do it together.together.

For more information on formulas and For more information on formulas and other things to know when ordering TPN, other things to know when ordering TPN, review the NICU manual @ review the NICU manual @ http://www.fellinahole.com/chartdata/nicu/tpn.html

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A Day in the LifeA Day in the Life

7am is the usual designated start time. Throw 7am is the usual designated start time. Throw your things in the call room and come on in.your things in the call room and come on in.

You should pull your sleeves up and scrub, You should pull your sleeves up and scrub, surgical style, at the big sink when you get surgical style, at the big sink when you get here. here.

Find the resident who was on call and get sign-Find the resident who was on call and get sign-out from the night before. That should include out from the night before. That should include all labs and films that were designated for the all labs and films that were designated for the AM, which makes your life a LOT easier.AM, which makes your life a LOT easier.

The most senior resident on your team will The most senior resident on your team will distribute the overnight admissions – don’t distribute the overnight admissions – don’t forget to get vitals on the new admission, too.forget to get vitals on the new admission, too.

All Is and Os are computerized now, so find one All Is and Os are computerized now, so find one and start your numbers.and start your numbers.

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Crunching NumbersCrunching Numbers

Your most important Your most important job in the morning is job in the morning is to get the to get the “numbers” on all of “numbers” on all of your patients. your patients.

For the first week of For the first week of life (days 1 through life (days 1 through 7), all numbers are 7), all numbers are based on birth based on birth weight.weight.

Starting day 8, you Starting day 8, you can use actual can use actual weight.weight.

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Crunching more Crunching more numbers…numbers… It’s important to keep It’s important to keep

meds and levels meds and levels updated. Be sure, even updated. Be sure, even if your kid has been off if your kid has been off caffeine for a week, a caffeine for a week, a covering attending will covering attending will want to know the last want to know the last caffeine level. You don’t caffeine level. You don’t have to list ALL of the have to list ALL of the result as you make result as you make sheets, just the most sheets, just the most recent.recent.

The last big box is for The last big box is for the plan, which you can the plan, which you can scribble in on rounds. scribble in on rounds. (We’ll get to rounds (We’ll get to rounds later.)later.)

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Back to crunching Back to crunching numbers…numbers… Little kids need fluids. Their total fluids Little kids need fluids. Their total fluids

will vary with their gestational age and will vary with their gestational age and issues. Most kids will either start with issues. Most kids will either start with 100cc/kg/day (little kids) or 80cc/kg/day 100cc/kg/day (little kids) or 80cc/kg/day (bigger) and we’ll work up from there.(bigger) and we’ll work up from there.

You care about two thingsYou care about two things– 1. How many cc/kg/day the baby is getting1. How many cc/kg/day the baby is getting– 2. How many kilocals/kg/day the baby is 2. How many kilocals/kg/day the baby is

gettinggetting Kids get fluids in 2 ways: parenteral and Kids get fluids in 2 ways: parenteral and

enteral. Enteral is easy so we’ll do that enteral. Enteral is easy so we’ll do that first.first.

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Total fluid volumeTotal fluid volume

Calculating PO fluidsCalculating PO fluids

The number designation of The number designation of formula (E20, S24) denotes how formula (E20, S24) denotes how many many kcals per ouncekcals per ounce a formula a formula has.has.

You don’t really care about You don’t really care about ounces, though. You want ccs. ounces, though. You want ccs. And there are 30cc to an ounce.And there are 30cc to an ounce.

Therefore the general rule is Therefore the general rule is that: that:

kcals in formulakcals in formula = kcals/cc = kcals/cc 30cc30cc

It then follows that: It then follows that:

Total caloriesTotal calories

Hints, tips and tricks• rice is 1 kcal/cc• breast milk is 20kcal/30cc or 0.67kcal/cc

cc/kg/day = cc/kg/day = total ccs POtotal ccs PO weight in kgweight in kg

kcals/kg/day = kcals/kg/day = kcals/cc x total cc POkcals/cc x total cc PO weight in kgweight in kg

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Our running totalOur running total

cc/kg/daycc/kg/day kcal/kg/daykcal/kg/day

POPO PE24 (215cc) / 1.85kg PE24 (215cc) / 1.85kg = = 116116

(215cc)(0.8) / 1.85kg =(215cc)(0.8) / 1.85kg =

93 93

CHOCHO

ProteiProteinn

LipidsLipids

OtherOther

TotalTotal 116116 9393

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TPN: DextroseTPN: DextroseTotal fluid volumeTotal fluid volume Total caloriesTotal calories

• First you need to figure out First you need to figure out how many kcals per cc your how many kcals per cc your dextrose is giving you. This dextrose is giving you. This formula is true for all formula is true for all formulations of TPN: formulations of TPN:

(% dextrose)(3.4)(% dextrose)(3.4) = kcals/cc = kcals/cc 100100

Hints, tips and tricks• Lipids don’t count in the total volume of TPN (they run in their own bag) but protein does! Therefore, protein adds additional calories without adding additional fluid.

cc/kg/day = cc/kg/day = total cc TPN total cc TPN weight in kgweight in kg

kcals/kg/day = kcals/kg/day = (kcals/cc)(cc (kcals/cc)(cc TPN)TPN) weight in kgweight in kg

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POPO PE24 (215cc) / 1.85kg PE24 (215cc) / 1.85kg = =

116116

(215cc)(0.8) / 1.85kg = (215cc)(0.8) / 1.85kg = 93 93

CHOCHO D10 (81.8cc) / 1.85kg D10 (81.8cc) / 1.85kg ==

4444

(81.8cc)(0.34) / 1.85kg =(81.8cc)(0.34) / 1.85kg =

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ProteiProteinn

LipidsLipids

OtherOther


2424

TPN: ProteinTPN: ProteinTotal fluid volumeTotal fluid volume Total caloriesTotal calories

• First you need to go to the TPN bag First you need to go to the TPN bag itself and note two things: order itself and note two things: order volume and trophamine (protein). volume and trophamine (protein). • Amount of protein is dependent on Amount of protein is dependent on how much is in the bag and how much how much is in the bag and how much of the bag the baby got.of the bag the baby got.

Kcals/kg/day = Kcals/kg/day = TrophamineTrophamine x total cc TPN x x total cc TPN x 4 4 order volume weight in order volume weight in kgkg

00

2525




116116

(215cc)(0.8) / 1.85kg = (215cc)(0.8) / 1.85kg = 93 93


4444

(81.8cc)(0.34) / 1.85kg =(81.8cc)(0.34) / 1.85kg =

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ProteiProteinn

00 (14/500) x 81.8 x (4/1.85)(14/500) x 81.8 x (4/1.85) ==

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LipidsLipids

OtherOther


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TPN: LipidsTPN: LipidsTotal fluid volumeTotal fluid volume Total caloriesTotal calories

• First you need to figure out First you need to figure out how many kcals per cc your how many kcals per cc your lipids are giving you. This lipids are giving you. This formula is simply: formula is simply:

cc/kg/day = cc/kg/day = total cc lipids total cc lipids weight in kgweight in kg

kcals/kg/day = kcals/kg/day = (2)(cc of lipids)(2)(cc of lipids) weight in kgweight in kg

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116116

(215cc)(0.8) / 1.85kg = (215cc)(0.8) / 1.85kg = 93 93


4444

(81.8cc)(0.34) / 1.85kg =(81.8cc)(0.34) / 1.85kg =

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ProteiProteinn

00 (14/500) x 81.8 x (4/1.85)(14/500) x 81.8 x (4/1.85) ==

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LipidsLipids IL (44cc) / 1.85 kg = IL (44cc) / 1.85 kg =

2222(44cc)(2) / 1.85kg = (44cc)(2) / 1.85kg =

4646

OtherOther


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Numbers: OtherNumbers: Other

Anything dripping in (morphine, Anything dripping in (morphine, sodium acetate, etc.) counts for sodium acetate, etc.) counts for cc/kg/day but provides no calories.cc/kg/day but provides no calories.

Anything being put out (ie OG, repogel) Anything being put out (ie OG, repogel) must be must be subtractedsubtracted from cc/kg/day from cc/kg/day

For those who are a little more high-For those who are a little more high-tech, check out the NICU calculator tech, check out the NICU calculator (peds drive (peds drive NICU folder NICU folder NICU NICU documents.)documents.)

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Rounding with the Rounding with the AttendingAttending It’s usually attending dependent, but expect to round It’s usually attending dependent, but expect to round

every day at around 9am. (Dr. Shah is the exception – every day at around 9am. (Dr. Shah is the exception – he rounds early and fast, so stay on your toes!)he rounds early and fast, so stay on your toes!)

Attendings will either round with residents and NNPs Attendings will either round with residents and NNPs altogether or separately. It varies from attending to altogether or separately. It varies from attending to attending and day to day.attending and day to day.

Verbal presentations follow the flow sheet exactly:Verbal presentations follow the flow sheet exactly:– One liner on history – “Ex 33One liner on history – “Ex 331/7-1/7-weeker with resolving weeker with resolving

RDS, status post ROS.”RDS, status post ROS.”– DOL, weight, and weight changeDOL, weight, and weight change– What the baby is feeding (PE24), how much (27.5-30cc), What the baby is feeding (PE24), how much (27.5-30cc),

how often (Q3H) and route (nipple vs. NG tube).how often (Q3H) and route (nipple vs. NG tube).– Then just read off the remaining columns (cc/kg/day, Then just read off the remaining columns (cc/kg/day,

kcal/kg/day, UOP, stools) all the way to As/Bs.kcal/kg/day, UOP, stools) all the way to As/Bs.– A good order for the rest is meds A good order for the rest is meds new labs new labs new new

films/other studies films/other studies other changes made the day other changes made the day before before any new developments. any new developments.

– As the plan is discussed, write it in the lower right box.As the plan is discussed, write it in the lower right box.

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IHI/Daily GoalsIHI/Daily Goals

While you’re presenting, While you’re presenting, another resident (or the another resident (or the fellow) will get the “IHI” form – fellow) will get the “IHI” form – NICU daily goals and plan of NICU daily goals and plan of care – from it’s section in the care – from it’s section in the thin blue bedside chart.thin blue bedside chart.

Nurses fill out the left side, it’s Nurses fill out the left side, it’s our job to fill out the right side. our job to fill out the right side.

Everyone present at the Everyone present at the bedside should sign the form bedside should sign the form on page 2.on page 2.

There is an “IHI fellow” who There is an “IHI fellow” who will round on patients under will round on patients under 1500g. The nurses read off 1500g. The nurses read off the IHI and a more in-depth the IHI and a more in-depth interdisciplinary discussion interdisciplinary discussion takes place. Formal “IHI takes place. Formal “IHI rounds” usually happen before rounds” usually happen before attending rounds. You should attending rounds. You should attend if the IHI rounds are attend if the IHI rounds are happening on one of your happening on one of your patients.patients.

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OrdersOrders

During rounds, while you’re presenting, another During rounds, while you’re presenting, another resident (or fellow) will usually put in orders for you resident (or fellow) will usually put in orders for you depending on what is being discussed. Don’t forget to depending on what is being discussed. Don’t forget to come back and check to make sure those orders were come back and check to make sure those orders were actually picked up. People get busy.actually picked up. People get busy.

Even though orders are written on the computer, you Even though orders are written on the computer, you have to show all (virtual) math. When ordering have to show all (virtual) math. When ordering Zantac, you should pick the “2mg/kg” option so the Zantac, you should pick the “2mg/kg” option so the computer does the math for you.computer does the math for you.

Zantac (2mg/kg/day)(1.04kg) = 2.08; round to 2mg Zantac (2mg/kg/day)(1.04kg) = 2.08; round to 2mg PO PO

Qday.Qday. Every time TPN is sent from pharmacy (usually 3 in Every time TPN is sent from pharmacy (usually 3 in

the afternoon every day) you’ll need to set a rate.the afternoon every day) you’ll need to set a rate. Make sure to tell a nurse when you’ve written an Make sure to tell a nurse when you’ve written an

order. It should pop up on her task list but you never order. It should pop up on her task list but you never know.know.

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Order RewritesOrder Rewrites

CPOE makes order rewrites obsolete.CPOE makes order rewrites obsolete. However, it is prudent and However, it is prudent and

necessary to check every order necessary to check every order every day to make sure that you every day to make sure that you haven’t hit a haven’t hit a soft stop and it hasn’t fallen off of soft stop and it hasn’t fallen off of the nurse’s MAR.the nurse’s MAR.

Compare active orders to what the Compare active orders to what the patient should be getting to exactly patient should be getting to exactly what the patient is getting (MAR) what the patient is getting (MAR) every day.every day.

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Med RoundingMed Rounding

The NICU has The NICU has standardized drug standardized drug dosing by instituting dosing by instituting rounding policies on rounding policies on specific drugs.specific drugs.

These are also found These are also found in the front of red in the front of red team’s yellow binder.team’s yellow binder.

Highlighted drugs Highlighted drugs are very commonly are very commonly prescribed, so if prescribed, so if you’re going to you’re going to remember any off remember any off the cuff, it’s these.the cuff, it’s these.

Adapted from NICU Manual, Annie Rohan, NNP

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The Delivery Room and The Delivery Room and Operating RoomOperating Room Go to lots of deliveries. You’ll learn a lot and Go to lots of deliveries. You’ll learn a lot and

staff is very eager to each.staff is very eager to each. At first, you’ll attend all deliveries with someone At first, you’ll attend all deliveries with someone

more experienced – a fellow or an NP.more experienced – a fellow or an NP. After attending three, you’re certified to go to After attending three, you’re certified to go to

uncomplicated deliveries alone (just you and the uncomplicated deliveries alone (just you and the DR nurse). However, if you’re uncomfortable DR nurse). However, if you’re uncomfortable attending a delivery by yourself, someone will attending a delivery by yourself, someone will always be there to go with you. You’re never always be there to go with you. You’re never truly alone.truly alone.

You’ll You’ll nevernever go to complicated deliveries on your go to complicated deliveries on your own. own.

When you go to the OR and you’re the one When you go to the OR and you’re the one catching the baby, you’ll have to scrub in catching the baby, you’ll have to scrub in surgical style. Don’t forget your hat and mask. surgical style. Don’t forget your hat and mask.

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Responsibilities in the Responsibilities in the DR/ORDR/OR The attendings, NPs and fellows will go over The attendings, NPs and fellows will go over

DR/OR proceedings in more depth. However, DR/OR proceedings in more depth. However, be aware that your primary role is airway – be aware that your primary role is airway – which puts you at the head of the radiant which puts you at the head of the radiant warmer. Review your neonatal resuscitation warmer. Review your neonatal resuscitation handbook – it helps.handbook – it helps.

You also will need to assign the APGAR score You also will need to assign the APGAR score and write a very brief note in the birth report and write a very brief note in the birth report detailing why you were called and what kind detailing why you were called and what kind of resuscitation took place (even if it was of resuscitation took place (even if it was only stimulation and bulb suction.)only stimulation and bulb suction.)

If the baby comes back to the NICU with you, If the baby comes back to the NICU with you, take the yellow copy of the birth report. If take the yellow copy of the birth report. If the baby goes to newborn, you don’t have to the baby goes to newborn, you don’t have to take anything back with you.take anything back with you.

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NICU Admission NICU Admission CriteriaCriteriaThe following babies The following babies mustmust be admitted to NICU: be admitted to NICU: Babies Babies less than 35less than 351/71/7 weeks weeks as documented on the yellow 'Birth as documented on the yellow 'Birth

Record' Record' and less than 2000 gmsand less than 2000 gms. These babies must come to the . These babies must come to the NICU for a period of observation to ensure normal transition.NICU for a period of observation to ensure normal transition.

Infants >35 weeks have no specific length of time they must stay in Infants >35 weeks have no specific length of time they must stay in the NICU. In general the transition period should be no less than 4 the NICU. In general the transition period should be no less than 4 hours.hours.

Infants <35 weeks must stay for a minimum of 24 hours of Infants <35 weeks must stay for a minimum of 24 hours of cardiopulmonary monitoring.cardiopulmonary monitoring.

Any baby who shows signs of delayed transition/physiologic Any baby who shows signs of delayed transition/physiologic instability, including tachypnea, grunting, flaring, etc., should come instability, including tachypnea, grunting, flaring, etc., should come to NICU for observation and monitoring, but as above, do not have to to NICU for observation and monitoring, but as above, do not have to stay once normal transition is ensured. Keep in mind that normal stay once normal transition is ensured. Keep in mind that normal newborn nursery has limited ability to monitor babies, both in terms newborn nursery has limited ability to monitor babies, both in terms of equipment and staff.of equipment and staff.

5 minute APGAR 5 minute APGAR << 6 6 HypoglycemiaHypoglycemia Maternal temp Maternal temp >>100.4 and/or any documented diagnosis of 100.4 and/or any documented diagnosis of

chorioamnionitischorioamnionitis Infants who receive naloxone (Narcan) at delivery (for 24 hrs of Infants who receive naloxone (Narcan) at delivery (for 24 hrs of

monitoring)monitoring)

From from NICU Manual, Kathy Gilsbach, RN, MS

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NICU Admission OrdersNICU Admission Orders

When a baby is admitted to the NICU, after he or When a baby is admitted to the NICU, after he or she is stabilized, the most important thing to do she is stabilized, the most important thing to do is write the admission orders – now made super is write the admission orders – now made super simple with CPOE’s power plans. Pick the one simple with CPOE’s power plans. Pick the one that fits your patient the best (“Full term infant that fits your patient the best (“Full term infant with congenital heart disease”) and all you have with congenital heart disease”) and all you have to do is check what you want.to do is check what you want.

One of the fellows or one of the fabulous One of the fellows or one of the fabulous respiratory therapists will be on hand to show respiratory therapists will be on hand to show you how they like to do respiratory orders. For you how they like to do respiratory orders. For every change in vent settings or mode of every change in vent settings or mode of support, you’ll have to write a new order.support, you’ll have to write a new order.

Unlike on the floor, residents don’t write an Unlike on the floor, residents don’t write an admission note. The fellow will take care of that. admission note. The fellow will take care of that. However, that doesn’t mean you don’t have work However, that doesn’t mean you don’t have work to do.to do.

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Admission Paperwork: Important Info to Know Maternal History

– Mom’s chart/Mom herself (best)– The CIS system

The computer closest to the clinicians room with the rolly mouse is the CIS computer. Your login is whatever you use to check your mail (ie LSmith) and the password is “baby.”

Select the mom that you’re interested in and surf around to see what you can find.

It will, at the very least, have her age, her parity notation and her prenatal labs.

How to: security login select a patient– Powerchart/Eclipsys

Birth History – Birth report – yellow copy

Vitals– The Nurses’ Admission packet will detail the initial vitals and their

physical. Blood Type/Antibody Information

– Cord Blood pH – Mom’s Powerchart under “Last 48 hours” tab– Baby’s blood type/antibody – Baby’s Powerchart ONLY if cord

blood is released

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Admission Paperwork: Your Arsenal The following goes into the appropriate

team’s binder:– Divider: Take a sheet of stickers and

make a divider.– Facesheet– Flowsheet– Ballard Score and Growth Chart– Initial Physical

Attending must sign this Add the new patient to the appropriate

team list. Don’t forget to consent the mom.

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The Daily Grind: Progress Notes and Updating the List Progress Notes

– There are post-call days, lecture days, etc. that make note-writing difficult, but do the best you can.

– Examine your babies every day regardless of how busy it is. Try to coordinate your exam with “hands-on” nursing so you don’t disturb the baby too much.

Updating the list– If you’re not the person on call, you should

update the list before you leave. A good habit to have is to update the list twice – once after rounds and once before you leave.

– If you’re the person on call, you’ll end up updating the list a hundred times. It’s inevitable.

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Discharge Checklist

Discharge SummaryDischarge Summary In thin blue bedside chart or have the clerk print oneIn thin blue bedside chart or have the clerk print one Fill in all pertinent info and all newborn screens done (not just the most Fill in all pertinent info and all newborn screens done (not just the most

recent)recent) Fill in ALL follow-up appointments with the name of the physician, phone Fill in ALL follow-up appointments with the name of the physician, phone

number and time-frame.number and time-frame. Attendings must sign the bottomAttendings must sign the bottom

Discharge PhysicalDischarge Physical Same form as admission physical, just circle “discharge” on top.Same form as admission physical, just circle “discharge” on top. No need to fill out the history section again, just cross it out and write “see No need to fill out the history section again, just cross it out and write “see

admission physical.”admission physical.” Once again, check for a red reflex and have the attending sign at the bottom.Once again, check for a red reflex and have the attending sign at the bottom.

Informing the PMDInforming the PMD The pediatricians appreciate a heads up about the patients before they are The pediatricians appreciate a heads up about the patients before they are

seen.seen. Call the PMD and give a brief history.Call the PMD and give a brief history.

Discharge OrdersDischarge Orders Dictation and BeyondDictation and Beyond

Write the dictation confirmation number on the facesheet Write the dictation confirmation number on the facesheet Move the patient’s paperwork from the “admission” section of your binder to Move the patient’s paperwork from the “admission” section of your binder to

the “discharge” section.the “discharge” section. Remove the patient from the list.Remove the patient from the list.

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Signing Out

If you’re not on call, you should be able to sign out to the on-call resident as early as 3pm, as long as all your work is done and there’s nothing else going on.

Update the list and give the on-call resident a copy. Make sure to sign-out anything pending overnight and for the AM.

If the on-call resident is on a different team, it’s probably prudent to give a little background on your patients, especially new ones (admitted in the last 3 days).

There is no “formal” sign out. Just find the on-call resident and ask if he or she minds you signing out.

Remember to also sign out your patients to a teammate before you leave for clinic.

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Call: Weeknights

Weeknights– You’re in charge of all the red and green

resident babies from sign-out until 7am the next morning.

– There will be an attending, an NNP and a fellow on with you at night. However, you’re first in line if there’s an issue with a resident baby – the call will come to you.

– You and the NNP will alternate delivery and admission responsibilities.

– You should wake up early enough in the morning to get all of the pending labs, update the list and do all of your numbers before the rest of the team gets there at 7am.

Call: WeekendsCall: Weekends

Friday– Same as weeknights, except before signing out to the

resident on Saturday morning, you should do all the numbers for every patient on your team.

Saturday – Saturday is the most labor intensive day.– Saturday morning, you’ll have to do the numbers for the

patients that the Friday night resident didn’t take care of.– Then, on Sunday morning, you should do the numbers for

every patient on your team, as well as getting the labs, updating the list, etc.

Sunday– Sunday morning numbers for patients the Saturday

resident didn’t do.– Monday morning, you can just do your own patients’

numbers.

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