NICU

Orientation Manual
UNM, Division of Neonatology 20112012

JMRael,MD 20112012

Neonatology Handbook
Table of Contents Introduction to the NICU Core Competencies Evaluation Process Neonatology Core Curriculum Intern and Sub-Intern Orientation Hygiene and Dress Code Examining Patients Nursing Staff Expectations NICU Staff Rotation Schedule and Expectations Calling in Sick Daily Rounds Sign Out Rounds Deliveries Transferring Patients to ECN/ICN Kardex Sheets Daily Baby Consult Services Family Communication Confidentiality Teaching and Conferences Neonatal Resuscitation Counseling for L & D Admissions NICU Forms Powerchart NICU Quirks Interim Summaries Discharges Procedure Notes and Consents Medication Orders Deaths Special Delivery Program Pediatric Hospice: UNM Mariposa Program Neonatology Website NICU Guidelines TPN Cheat Sheet UAC and UVC Placement Endotracheal Intubation Commonly Used NICU Drugs Discharge to Home Checklist 2 2-4 5 6-10 11 11 11 11 11-12 12 12 12-13 13 13 13 13 14 14 14 14 15 15 16 16 16 16-17 17 17 17 17 17 18 18 18 19-21 22 23 23 24-25 26

NICU Orientation A Brief Introduction Welcome to the Newborn Intensive Care Unit (NICU) at the University of New Mexico Children's Hospital. The NICU at the Children's Hospital opened in 1971. Before the program's inception in 1971, the neonatal mortality rate in New Mexico was 15:1,000 live births, compared to 14.2 nationwide. As of 2006, the infant mortality rate in NM was 5.7, compared to 6.7 nationwide. The UNM Hospital has between 3,500 to 4,000 deliveries per year. Our neonatology service admits approximately 700 infants per year, with about 75% originating from our own delivery service and 25% as neonatal transports. Our NICU encompasses 36 level III beds and 28 level II beds. Patient care in the NICU is multidisciplinary and is provided by the attending Neonatologist, fellows, resident house-staff, neonatal nurse practitioners (NNPs), physician assistants (PAs), sub-interns, nurses, respiratory therapists, developmental care specialists, nutritionists, lactation consultants, social workers, etc. Patients are distributed among three different areas: the Newborn Intensive Care Unit, and the Intermediate Care Nursery (ICN), both located on the fourth floor of the Pavilion; and the ICN-3, located on the third floor of the Pavilion. Pediatric residents rotate through the NICU for one month per year during their residency. The next several pages identify the objectives and curriculum for residents in the NICU and are in three sections: 1) 2) 3) ACGME Resident Objectives and Evaluation Neonatology Core Curriculum Checklist for Procedures

CORE COMPETENCIES SUBINTERN/INTERN/RESIDENT OBJECTIVES, EXPECTATIONS AND EVALUATION The goal of the Childrens Hospital of New Mexico NICU rotation is to develop the ability of residents to evaluate and manage critically ill infants with a broad range of medical and surgical problems. Learning will occur in a multidisciplinary team-based system. Interns/Residents will be the primary caregivers for their patients, under the close supervision of staff neonatologists, fellows, nurse practitioners, and physician assistants. The ACGME requires that the six Core Competencies be integrated into the curriculum. The objectives of this rotation are designed to further the residents development of the ACGME core competencies:

Patient Care Provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health Interns/Residents will review the perinatal history and prenatal records, gather additional information if needed, and perform a complete infant physical examination upon the patients admission After evaluating the patient, they will formulate a differential diagnosis, and plan appropriate diagnostic and therapeutic interventions (in coordination with the attending neonatologist and/or fellow and primary neonatal nurse) With complete and thoughtful review of diagnostic results and frequent reassessment of the patient, residents will reconsider the clinical status of the patient, along with the differential diagnoses on a continuing basis, making changes to management plans as appropriate Interns/Residents will be mindful of routine health care maintenance for infants under their care They will order newborn screening, hearing screens, active and passive immunizations, car seat testing, and ophthalmologic examinations as indicated As medically indicated, residents will perform appropriate diagnostic and therapeutic procedures after obtaining informed consent from the patient and/or family, with supervision from the attending neonatologist. Interns/Residents will document procedures in the chart and in their personal logbooks (new innovations) Interns/Residents will attend all deliveries that they can, whether on admit team or not Medical Knowledge Demonstrate knowledge of established and evolving biomedical, clinical, epidemiological and social-behavioral sciences, as well as the application of this knowledge to patient care Interns/Residents will draw from the wide range of patient diagnoses requiring admission to a level III neonatal intensive care unit to broaden their exposure to a wide range of complex disease processes

In developing a differential diagnosis, the intern/resident will demonstrate his ability to apply analytical thinking to the clinical situation The patient population at this referral center is based on a high-risk obstetrical service, as well as infants transferred from outside hospitals for higher levels of care (those requiring nitric oxide therapy, extracorporeal membrane oxygenation, and pediatric surgical interventions, etc.) During this rotation, it is expected that interns/residents will manage infants diagnosed with, but not limited to: Congenital abnormalities Congenital pneumonia Hyperbilirubinemia Meconium aspiration Necrotizing enterocolitis Neonatal infectious diseases caused by bacteria, viruses, parasites Persistent pulmonary hypertension of the newborn Pneumothorax Prematurity (including apnea of prematurity, retinopathy of prematurity) Respiratory distress syndrome Interns/Residents will learn about the principles and application of parenteral and enteral nutrition, as well as fluid and electrolyte therapy in neonates Interns/Residents will work with respiratory therapists and other team members to manage conventional and high frequency mechanical ventilation of sick neonates

Practice-based Learning and Improvement Demonstrate the ability to investigate and evaluate care of patients, to appraise and assimilate scientific evidence, and to continuously improve patient care based on constant self-evaluation and life-long learning. Develop skills and habits to be able to meet the following goals: Identify strengths, deficiencies, and limits in one's knowledge and expertise Set learning and improvement goals Identify and perform appropriate learning activities Systematically analyze practice using quality improvement methods Implement changes with the goal of practice improvement Incorporate formative evaluation feedback into daily practice Locate, appraise, and assimilate evidence from scientific studies related to patients' health problems It is expected that decisions about patient care will involve review, synthesis and application of studies available in the literature Daily work rounds will include discussion of information gathered from the literature by residents and other team members Use information technology to optimize learning Participate in the education of patients, families, students, residents and other health professionals Interns/Residents will attend regular lectures on topics important to the care of neonates given by the neonatology staff (see attached schedule) Interns/Residents will take part daily in radiology rounds, reviewing radiographic imaging of their patients with pediatric radiology attendings and the neonatology team Interns/Residents are expected to attend radiology rounds from Monday through Friday at 1130 in the Pediatric Radiology Suite Interpersonal and Communication Skills Demonstrate interpersonal and communication skills that result in the effective exchange of information and collaboration with patients, their families, and health professionals At all times, it is the residents responsibility to educate and work with the patient and family, maintaining a strong therapeutic alliance Interns/Residents will take part in daily collaborative interdisciplinary team rounds Interns/Residents will meet regularly with parents to listen to their concerns and keep them updated on their childs condition and care plan Interns/Residents will coordinate consult services and facilitate discussion among clinician members of the team and the family

Daily notes in the chart clearly documenting patients progress, diagnostic results and ongoing plan will be completed in order to maintain an accurate medical record and share information among team members Interns/Residents will help arrange follow up with the NICU follow-up clinic and subspecialists as indicated, in addition to the patients primary care provider Interns/Residents will communicate with the patients primary care physician on a regular basis, especially near the time of discharge When leaving the rotation, an off-service summary will be prepared and made part of the medical record Interns/Residents will receive regular verbal feedback and a final written evaluation from the entire Division of Neonatology that will be placed in their permanent record Interns/Residents will use constructive feedback to guide their efforts in ongoing learning and self-improvement

Professionalism Demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles: Compassion, integrity, and respect for others Responsiveness to patient needs that supersedes self-interest i.e. Patient care is first and foremost, answer pages in a timely manner, arrange consults ASAP, do not wait until notes are done, your responsibility is to the patient Respect for patient privacy and autonomy Accountability to patients, society and the profession Sensitivity and responsiveness to a diverse patient population, including but not limited to diversity in gender, age, culture, race, religion, disabilities, and sexual orientation Interns/Residents, during this rotation, may deal with issues of end of life care, withdrawal of support, potential for long-term disabilities and chronic illness. Residents will take part in discussions between attending physicians and patients/families about end of life care decisions

Systems-based Practice Demonstrate an awareness of and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care: Work effectively in various health care delivery settings and systems relevant to their clinical specialty Coordinate patient care within the health care system relevant to their clinical specialty Incorporate considerations of cost awareness and risk-benefit analysis in patient and/or population-based care as appropriate Advocate for quality patient care and optimal patient care systems Work in interprofessional teams to enhance patient safety and improve patient care quality Participate in identifying system errors and implementing potential systems solutions

EVALUATION PROCESS The evaluation process for all interns/residents should be ongoing. Formal feedback should be provided at the end of each rotation by the attending /fellow to the intern/resident. In addition, the Division of Neonatology evaluates each intern/resident as a group. The form used is the general Pediatric Resident Evaluation Form. Objectives by Year The NICU experience at UNM consists of one month rotations during their subintern rotations and each of the PL-1, PL-2 and PL-3 years. The following are suggested goals as to what might be accomplished at each level: Phase III Medical Student: Is courteous, kind, caring, and conducts him/herself in a respectful manner Accepts responsibility and conducts him/herself in an honest manner Arrives punctually Consistently and reliably collects and reports patient data Communicates data orally in an organized and logical manner Recognizes normal and abnormal Interprets abnormal findings and tests Identifies and prioritizes problems and is able to rank and justify a differential diagnosis o Focus on identification of problems and pathophysiology Customizes plans to meet the patients needs and modifies plans based on results and response to treatment Gain delivery room and procedure experience Identifies knowledge gaps and addresses them Shares new information with others Evaluates the quality of evidence found Accepts responsibility for education of the team PL-1 Focus on identification of problems and pathophysiology Gain delivery room and procedure experience Evaluation of nutritional needs Communication with the care team and parents Attend all acute calls to the delivery room (meconium, difficult delivery, etc) Practice collaboration with NNPs/PAs Provide primary care of neonates with mild-moderate complexity PL-2 Focus on more independent management of problems Work on gaining some independence in the delivery room Master common procedures Provide primary care of neonates with increased complexity Attend all acute calls to the delivery room (meconium, difficult delivery, etc) Practice collaboration with NNPs/PAs At the end of rotation, assess accomplishments and outline goals for later rotations PL-3 Focus on independent management of general and more complex neonatal problems Provide primary care for infants with more complex disease Take primary responsibility for all resuscitations you attend (meconium, difficult delivery, etc.) Practice collaboration with NNPs/PAs Consult with mothers prior to high risk delivery (with NNP/PA, fellow or attending) Evaluate progress at the end of the rotation

NEONATOLOGY CORE CURRICULUM The core curriculum outlined below was developed based on the experiences you will encounter in the NICU at UNM. The following goals are to be achieved by instruction in the NICU and by self-directed learning. For additional topics, please refer to the AAP Guidelines What you need to know about neonatology for the general pediatrician.

GOAL I:

Perinatal Prevention: Understand the pediatricians role in perinatal prevention and become an active advocate to reduce morbidity and mortality from high risk pregnancies Identify and describe strategies to reduce fetal and neonatal mortality o Including use of group B strep prophylaxis, perinatal steroids, etc. Understand and know how to evaluate: o Basic vital statistics that apply to newborns (neonatal and perinatal mortality, etc) o Prenatal services available in ones region o Tests commonly used by obstetricians to measure fetal well-being o Neonatal transport systems Describe effective intervention programs for teens and other high risk mothers Recognize potential adverse outcomes for the fetus and neonate of common prenatal and perinatal conditions Demonstrate the pediatricians role in assessment and management strategies to minimize the risk to the fetus and/or newborn in the following situations: o Maternal infections/exposure to infection during pregnancy o Fetal exposure to harmful substances (alcohol, tobacco, environmental toxins, medications, street drugs) o Maternal insulin-dependent diabetes and pregnancy-induced glucose intolerance o Multiple gestation o Placental abnormalities (placenta previa, abruption, abnormal size, function) o Pre-eclampsia, eclampsia o Chorioamnionitis o Polyhydramnios o Oligohydramnios o Premature labor, premature ruptured membranes o Complications of anesthesia and common delivery practices (e.g. Cesarean, vacuum, forceps assisted, epidural, induction of labor) o Fetal distress during delivery o Postpartum maternal fever and infection o Maternal blood group incompatibilities o Other common maternal conditions having implications for the infants health SLE HELLP syndrome Maternal thrombocytopenia, etc.

GOAL II:

Resuscitation and Stabilization: Assess, resuscitate and stabilize critically ill neonates Explain and perform steps in resuscitation and stabilization: o Airway management o Vascular access o Volume resuscitation o Indications for and techniques of chest compressions o Resuscitative pharmacology o management of meconium deliveries Describe the common causes of acute deterioration in previously stable NICU patients Function appropriately in codes and neonatal resuscitations as part of the NICU team by: o Participating in resuscitations o Completing Neonatal Resuscitations Program (NRP) o Using neonatal resuscitation drugs appropriately o Understanding the transition period

 GOAL III:

Common Signs and Symptoms: Evaluate and manage, under supervision of the attending Neonatologist, patients with the signs, symptoms that present commonly in the NICU: o General: Feeding problems, history of maternal infection or exposure, hyperthermia, intrauterine growth failure, irritability, jitteriness, large for gestational age, lethargy, poor post-natal weight gain, prematurity (various gestational ages). o Cardiorespiratory: apnea, bradycardia, cyanosis, dehydration, heart murmur, hypertension, hypotension, hypovolemia, poor pulses, respiratory distress (flaring, grunting, tachypnea), shock. o Dermatologic: birthmarks, common skin rashes/conditions, discharge and/or inflammation of the umbilicus, hyper-and hypopigmented lesions, proper skin care for extremely premature infants. o GI/surgical: abdominal mass, bloody stools, diarrhea, distended abdomen, failure to pass stool, gastric retention or reflux, hepatosplenomagaly, vomiting. o Genetic/metabolic: apparent congenital defect or dysmorphic syndrome, metabolic derangements (glucose, calcium, acid-base, urea, amino acids, etc.) o Hematologic: abnormal bleeding, anemia, jaundice in a premature or seriously ill neonate, neutropenia, petechiae, polycythemia, thrombocytopenia. o Musculoskeletal: birth defects and deformities, birth trauma and related fractures, soft tissue injuries, dislocations. o Neurologic: birth trauma and related nerve damage, early signs of neurologic impairment, hypotonia, macrocephaly, microcephaly, seizures, spina bifida. o Parental stress and dysfunction: anxiety disorders, child abuse and neglect, poor attachment, postpartum depression, substance abuse, teen parent. o Renal/urologic: abnormal genitalia, edema, hematuria, oliguria, proteinuria, renal mass, urinary retention.

GOAL IV:

Common Conditions: Recognize and manage, under the supervision of a neonatologist, the following common conditions in patients encountered in the NICU: o General: Congenital malformations o Cardiovascular: cardiomyopathy, congenital heart disease (cyanotic and acyanotic - patent ductus arteriosus, ventricular septal defect, Tetralogy of Fallot, transposition of the great arteries, etc.), congestive heart failure, dysrhythmias (e.g. supraventricular tachyarrhythmia, complete heart block) o Genetic/endocrine disorders: abnormalities discovered from neonatal screening programs as they affect the premature infant, common chromosomal anomalies (Trisomy 13, 18, 21, Turners), inborn errors of metabolism, infant of a diabetic mother, infant of a mother with thyroid disease (e.g. maternal Graves Disease), uncommon conditions such as congenital adrenal hyperplasia, hypothyroidism, hyperthyroidism o GI/Nutrition: biliary atresia, breastfeeding support for mothers and infants with special needs (high risk premature, maternal illness, multiple birth, etc.), complications of umbilical catheterization, gastroesophageal reflux, necrotizing enterocolitis, nutritional management of high risk neonates or those with special needs (cleft lip/palate, other facial anomalies, etc.) o Hematologic conditions: hemorrhagic disease of the newborn, erythroblastosis fetalis, hemophilia, hydrops fetalis, hyperbilirubinemia, splenomegaly, anemia, polycythemia, DIC, autoimmune and isoimmune thrombocytopenia, neutropenia. o Infectious disease: central line infections, group B streptococcal infections, hepatitis, herpes simplex, immunization of the premature neonate, infant of mother with HIV, intrauterine viral infections, neonatal sepsis and meningitis, nosocomial infections in the NICU, syphilis, ureaplasma, varicella exposure. o Neurologic disorders: central apnea, CNS malformation (e.g. encephalocele, porencephaly, holoprosencephaly), drug withdrawal, hearing loss in high risk newborns (prevention and screening), hydrocephalus, hypoxic-ischemic encephalopathy, intraventricular hemorrhage, retinopathy of prematurity, seizures, spina bifida.

o o

Pulmonary disorders: atelectasis, bronchopulmonary dysplasia, meconium aspiration, persistent pulmonary hypertension of the newborn, pneumonia, pneumothorax, respiratory distress syndrome, transient tachypnea of the newborn. Renal: acute and chronic renal failure, hematuria, hydronephrosis, oliguria, proteinuria. Surgery: assess and participate in management under supervision of a pediatric surgeon or cardiac surgeon: congenital heart disease (cyanotic, patent ductus arteriosus, obstructive left-sided cardiac lesions, pre-and post-operative care), diaphragmatic hernia, esophageal or gut atresia, gastroschisis, omphalocele, intestinal obstruction, necrotizing enterocolitis, perforated viscus, Pierre Robin syndrome, volvulus

GOAL V:

Diagnostic Testing Under the supervision of a neonatologist, order and understand the indications for/limitations of and interpretation of laboratory and imaging studies unique to NICU setting Demonstrate understanding of common diagnostic tests and imaging studies used in the NICU by being able to: o Explain the indicators for and limitations of each study o Know or be able to locate readily gestational age-appropriate normal ranges (lab studies) o Apply knowledge of diagnostic test properties, including the use of sensitivity, specify, positive predictive value, negative predictive value, likelihood ratios, to assess the utility of tests in various clinical settings o Recognize cost and utilization issues o Interpret the results in the context of a specific patient o Discuss therapeutic options for correction of abnormalities Use appropriately the following evaluations that may have specific application to neonatal care: o Serologic and other studies for transplacental infection. o Direct and indirect Coombs tests. o Neonatal drug screening. o Cranial ultrasound for intraventricular hemorrhage. o Abdominal x-rays for placement of umbilical catheter. o Chest x-rays for endotracheal tube placement, air leak, heart size, and vascularity. Use appropriately the following laboratory tests when indicated for patients in the neonatal intensive care setting: o CBC with differential, platelet count, RBC indices o Blood chemistries: electrolytes, glucose, calcium, magnesium, phosphate o Renal function tests o Tests of hepatic function (PT, albumin) and damage (liver enzymes, bilirubin) o Serologic tests for infection (e.g., hepatitis, HIV). o CRP, ESR o Therapeutic drug concentrations o Coagulation studies: platelets, PT/PTT, fibrinogen, fibrin split products, Ddimers, DIC screen o Arterial, capillary, and venous blood gases o Detection of bacterial, viral, and fungal pathogens o Urinalysis o CSF analysis o Gram stain o Stool studies o Toxicology screens/drug levels o Other fluid studies (e.g. pleural fluid) o Newborn screening tests

Appropriately use the following imaging, radiographic or other studies when indicated for patients in the NICU setting: o Chest x-ray, abdominal series, skeletal survey o CT scans o MRI o Electrocardiogram and echocardiogram o Cranial ultrasonography

 GOAL VI:

Monitoring and Therapeutic Modalities: Understand how to use physiologic monitoring, special technology and therapeutic modalities used commonly in the care of fetus and newborn Demonstrate understanding of the monitoring techniques and special treatments commonly used in the NICU by being able to: o Discuss the indications, contraindications and complications o Describe the general technique for use in infants o Interpret the results of monitoring Use appropriately the following monitoring and therapeutic techniques in the NICU: o Physiologic monitoring of temperature, pulse, respiration, blood pressure o Pulse oximetry o Neonatal pain and drug withdrawal scales Demonstrate understanding of the following techniques and procedures used by obstetricians and perinatologists: o Fetal ultrasound for size and anatomy o Fetal heart rate monitors o Scalp and cord blood sampling o Amniocentesis o Cardiocentesis o Intrauterine transfusion including exchange transfusions o Chorionic villus sampling Use appropriately the following treatments and techniques in the NICU Monitor effects and anticipate potential complications specific to each: o Oxygen administration by hood, CPAP or assisted ventilation o Endotracheal intubation o Administration of surfactant therapy o Positive pressure ventilation and basic ventilator management o Phototherapy o Central hyperalimentation and parenteral nutrition o Enteral nutrition o Analgesic, sedatives and paralytics o Blood and blood product transfusions, including exchange transfusion o Vasoactive drugs (pressure and inotropes) o Judicious use of antibiotics o Administration of medications specific to the needs of the newborn (e.g., vitamin K) o Arterial puncture o Venous access by peripheral vein o Umbilical artery and vein catheterization o Chest tube placement o Paracentesis Describe home medical equipment and services needed for oxygen-dependent and technology-dependent graduates of the NICU (oxygen, apnea monitor, ventilator, home hyperalimentation, etc.) Use appropriate resources to facilitate the transition to home of the technologydependent neonate

GOAL VII: Professional Competencies in Brief: Maintain standards of professional performance in the NICU under the guidance of a neonatologist o Use a logical and effective approach to assessment and daily management of seriously ill neonates and their families Provide emotional, social, and culturally sensitive support to the NICU infant and family including those at home. o Demonstrate a commitment to acquiring the knowledge base expected of general pediatricians caring for seriously ill neonates o Know and/or access medical information efficiently, evaluate it critically, and apply it appropriately to the care of ill newborns o Function effectively as part of an interdisciplinary team member in the NICU o Maintain accurate, timely, and legally appropriate medical records in the critical setting of the NICU o Demonstrate knowledge, skills and attitudes needed for continuous selfassessment

o o o o

Use scientific methods, evidence and problem solving skills to investigate, evaluate, and improve ones patient care practice in the NICU setting Demonstrate a commitment to carrying out professional responsibilities while providing care in the NICU setting Practice ethically and within medical-legal constraints in caring for critically ill newborns Understand key aspects of health care systems, cost control and mechanisms for payment in the NICU setting Recognize the limits of ones knowledge and expertise and take steps to avoid medical error

CHECKLIST FOR PROCEDURES You should be able to describe the following procedures, including how they work and when they should be used: o Chest tube placement o Endotracheal intubation o Exchange transfusion knowledge of technique o Gastric tube placement (OG/NG) o Lumbar puncture o Arterial puncture o Medication delivery: endotracheal o Pulse oximeter: placement o Suctioning: nares, oral pharynx, trachea (newborn) o Umbilical artery and vein catheter placement o Ventilation: bag-valve-mask o Ventilation support: initiation o Indications: exchange transfusion

CHECKLIST FOR DIAGNOSTIC/SCREENING TESTS You should be able to describe the following tests or procedures, including how they work and when they should be used: o Physiologic monitoring interpretation: cardiac, pulse oximetry, end-tidal CO2 o Radiographic interpretation: abdominal x-ray, chest x-ray, head CT o Indications for: abdominal ultrasound, cranial ultrasound, GI contrast study o Hearing screening o Electrocardiogram (ECG): emergency interpretation

10

INTERN AND SUB-INTERN (MS-IV) ORIENTATION As an intern or sub-intern you will be buddied with an NNP/PA during your first day on the rotation. One week before the start of your rotation you should email John Arthur to obtain a username and password to daily baby. Daily baby is the current program used in the NICU for patient documentation. Sub-interns should report to the back team room, room 4727, the Friday before your rotation starts to get your patient assignments; interns and residents the day prior to your rotation. Please remember to bring a calculator your first day as well. You will also need to make sure your badge works, your pager is activated, you have access to powerchart. Your shift in the NICU begins at 7:00am. The NNP/PA you are teamed with will teach you how to pre-round on your patients, perform calculations, enter data into the Daily Baby computer system, go to L&D, etc. It is recommended that you TAKE NOTES during this first day. The number to the back team room is 272-4150. ROUTINE HYGIENE AND DRESS CODE It is required that you wash your hands at the scrub sink upon entering the NICU. The hand washing procedure is as follows: Arms must be bare to above the elbow Jewelry must be removed including rings and watches (Plain wedding bands are acceptable as they are smooth without multiple surfaces that can harbor microorganisms) o Each individual is responsible for securing his/her own jewelry Clothing sleeves must not reach longer than above the elbow Personnel must wash their hands and arms with the scrub brushes for a minimum 2 minute scrub Clean under nails with nail pick Wash hands to a point above the elbow using a hospital provided hand hygiene product Use appropriate technique for the hand hygiene product being used You are allowed to use antiseptic gel located throughout the unit to disinfect your hands instead of soap and water between patients. Wash your hands with soap and water every 10-15 uses of the gel. Abide by universal precautions and use gloves when in contact with bodily fluids. Scrubs must be worn during the rotation so that you are able to attend deliveries. Do not wear regular clothing, even on your clinic days. When going to L&D, scrubs are mandatory. The OB/GYN department is strict about this. Do not wear sweatshirts or sweaters, etc. over your scrubs when going to a delivery. In the unit you may wear a yellow cover gown (located near the scrub sinks in NICU) over your scrubs if you wish. Scrubs can be obtained from the pyxis located next to back team room. Do not wear your scrubs in from home. When you leave the unit, you should use a yellow gown or jacket to cover scrubs when outside unit (To keep them as clean as possible since we go into the OR for deliveries). A stethoscope is provided for each infant at the bedside. Use your own stethoscope for deliveries. EXAMINING PATIENTS Each patient must be examined every day. Ask the infants nurse when the best time to examine a baby would be, especially if the baby has been unstable. We try to limit the amount of times we move our patients. Move the patient gently and ask the nurse for assistance in examining your patients if necessary. It is poor bedside manner to examine a baby and leave them with a dirty diaper, unwrapped, or screaming. After examining an infant, position and wrap the infant as you found him/her. If the exam cannot be done before rounds then it can be done later in the day. NURSING STAFF EXPECTATIONS Introduce yourself and let the nurses know you are new to the unit. When you have new orders for the patients (other than during formal morning rounds) find the nurse and make him/her aware of the new orders. All fluids and meds are in per kilogram (eg. mg/kg/dose, mg/kg/day.) It is best to update the dosing weight and include it in the orders. You may be questioned about your orders, be prepared to clarify the plan of care for the patient. The nurses in the NICU are knowledgeable, are advocates for their patients, and will make suggestions. Always ask for their input they often have a good sense of how the patient is doing. Treat them respectfully. NICU STAFF NNP/PAs Our NNP/PA group is a wealth of knowledge and considered senior staff. They will be your resource for patient management, nutrition, deliveries, stabilization of newborns, and procedures. Check your patients out to your NNP/PA when you leave for clinic, resident school, or short days.

DEVELOPMENTAL CARE The developmental care team assesses each newborn admitted to the NICU. They provide a wide variety of invaluable services that are helpful in babies with chronic problems, feeding issues, and

11

neurological abnormalities. They play an important role in the development follow-up of our NICU graduates. Their names are listed in the pager number list found in this manual.

SOCIAL SERVICES All babies admitted to the NICU will have a social work intake interview by a social worker. It is beneficial to touch base with them if you have specific concerns regarding a family. They usually write a note in Daily Baby every few days. During the weekends, holidays and nights, an on-call social worker is available (call the operator 0 for the on-call social worker for emergencies). RESPIRATORY THERAPY A respiratory therapist is available in the unit at all times. They manage all of the ventilators, make changes, institute respiratory therapies, and run the blood gases. As an intern, an attending/fellow should be consulted on all blood gases before changes are made, before placing a patient on a ventilator, or before changing forms of ventilation. Do not make vent changes yourself. Order the change and then notify the nurse and the RT so that the change will occur in a timely manner. NUTRITIONIST Ann-Marie Yaroslaski (951-3371) is our nutritionist. She is often present in rounds to make recommendations. However, you must clear her recommendations with the attending prior to implementing them. There is a fluid and feeding guidelines card that will assist you in advancing feeds and adjusting TPN amino acids and intralipids on patients. Refer to the guidelines before rounds, and think about your feeding plan for the day. PHARMACIST Primarily Larry or Bonnie assigned to NICU. Present in the unit next to Charge nurses desk. Turn in TPN sheets to them with patient sticker on it. They follow medication levels (you order levels) and help you adjust dosing. CHARGE NURSE The NICU charge nurse attends all deliveries and coordinates (helps select patients) patients moving from NICU to ICN 4 or ICN 3. 410-6606

ROTATION SCHEDULE and EXPECTATIONS PGY-1s and medical students work day shifts and do not take night call. They work an average of 6 days a week in approximately 12-13 hour shifts, from 7am-8pm. PGY-2s and PGY-3s work 5-6 days per week with two weeks of day shifts and two weeks of night shifts. Day shifts are the same as PGY-1 day shifts, approximately 7am-8pm. Night call shifts are approximately 12-13 hours, lasting from 7pm-8am. For the night crew, it is important to be on time for 7pm sign-out. The next morning you are expected to help with sign-out. You might be expected to stay longer if something is going on at that time and extra help is needed (i.e. if a baby is deteriorating, a new admission comes in at that time, etc.). The resident schedules are meant to accommodate the 80 hr work week with some flexibility. It cannot be emphasized enough that your work needs to be done for your patients before you leave. It is inappropriate to leave work for the on call team that is your responsibility. Interns/residents are allowed one early day per week and should plan to leave no earlier than 2:00pm. All work must be done prior to leaving (notes written, consults called, etc). You should respond to all pages in a timely manner, whether your work is completed or not. Please let your attending/fellow know at the beginning of each week which day you would like to leave early so the team may round on your patients first. The day for your early day should not be a day when you are on the admit team, nor a clinic day if you happen to have AM clinic. Sign out to the NNP/PA on your team before you leave for the day. This also applies for clinic days and the Thursday Pediatric teaching afternoon. Notify the infants nurse as to who will be responding in your absence. Interns may not sign out to another intern. When you return from clinic, re-evaluate your patient and update yourself on any changes that may have occurred. CALLING IN SICK It is your professional responsibility to call in sick in a timely manner. Please call the sick call resident as soon as possible to ensure coverage for that day and/or evening. You must also call the house-staff office (Susan), the NICU team, and also the NICU fellow/attending to let them know that you will not be coming in to work due to illness. Sub-interns please call the back team room and notify the NNP/PAs that you will not be present (272-4150). ROUNDS You should be ready to round at 0900 every day. Rounds begin promptly at 9:00am on Tuesday and Thursday, and 0930 on Monday, Wednesday and Friday (teaching occurs from 0900-0930 on these days). You are expected to round with the entire team, unless it is your clinic, early day or resident school day. On

12

these days, you will be rounded with first on all of your patients. You will then be excused from rounds to take care of notes, consults, etc. On weekends, rounds generally begin at 0900. On weekends you generally round individually with the attending/fellow and then get your work done. All data should be collected (including checking blood culture results) and all patients should be seen and examined before rounds. The interns may discuss their patients with an NNP/PA, attending, fellow, or senior resident before rounds to formulate a plan on their patients. A well thought out plan will make rounds more efficient. Proposed TPN calculations should be done. Present your patient concisely from the Kardex. Practice your presentation so that it sounds polished. Update the Kardex daily and place them in the appropriate folders at the end of the day. Be prepared to discuss your patients on rounds, ie., if you have a patient with CDH you should have read on CDH and be prepared to answer questions/teach about what you have learned. As the intern/resident you should constantly be following up on your patients (blood gases, culture results, labs, urine output, how they are feeding, residuals, FiO2 requirements, apnea/bradycardic spells, radiology, consults, exam changes, etc.). Interns should update the fellow/attending with any significant changes, or concerns they have on their patients. Assess your patient and have a plan! SIGN OUT ROUNDS The attendings and fellows formally sign out to each other at 4:00pm. The NNP/subinterns/interns/residents sign out to the night call team at 7:00pm with the on-call fellow. Sign out rounds are NOT morning rounds all over again. You do not need to restate every number and event. Focus on the important issues that could come up at night. If you anticipate a problem, formulate a plan for the on-call team on how to deal with it. Let the team know about changes (or no changes) that should be made through the night. DELIVERIES: Go to as many as you can! Protected time is after 17:00 if your notes are not completed. You may be expected to write the delivery note and assign APGARS at the deliveries you attend. Whether you write the official delivery note or not, you should practice writing the delivery note on your own and assigning APGARS. The note should be written prior to leaving the delivery room. A sample delivery note is as follows: (Why are you there? How did they deliver? What did you do? How did they react? How did you leave them?) Peds attendance for ____________ (prematurity / meconium / c-section / vacuum assist / ..) Vertex/Breech through clear fluid /mec stained fluid /bloody fluid. Spontaneous cry with flexed tone at perineum (Or cried at delivery...) vs. weak cry with poor tone at perineum vs. no spontaneous cry or tone etc. Dried, stimulated and suctioned under radiant warmer. Vigorous respiratory effort (or continued weak/irregular cry); pink in RA; moving all extremities well, etc. Any abnormal physical exam findings must be documented (ie sacral dimple or 2 vessel cord). Comment on transition (expect normal transition, etc). Other things to include: breath sounds coarse, + void if s/he voids or + stool palate intact, why you did or did not intubate for meconium below the cords, how many times you suctioned; any interventions you provided (ie blow by O2 or CPAP you must document why, when and how long the intervention was provided and how the infant responded to the intervention; i.e. BBo2 at 1 minute for poor color x 30 sec with immediate improvement and infant weaned easily to RA). Shoulder dystocia state if pt moving both arms, clavicle with or without crepitus, good grasp bilaterally; vacuum extraction note neurologic status in particular, and scalp edema / caput/ bogginess, etc; forceps moving both upper extremities equally, asymmetric crying facies, bruising from forceps, etc. TRANSFERRING PATIENTS TO ECN/ICN In the ICN-3, if admitting or transitioning an infant, admit through powerchart and put admission note in clinical notes of patient. If transferring from NICU to ICN3, the patient must be discharged from daily baby with discharge summary. Call the attending in ICN3 to confirm acceptance and give report. Send copy of D/C summary with the infant to the ICN3. Write transfer orders, change location and service in powerchart, and do med rec. KARDEX SHEETS These data sheets are to be used to collect data on each patient. The on call team also uses these sheets for information on patients during call. Please dont take them home! It is your responsibility to keep the Kardex updated and complete, with all pertinent information and lab values recorded. The back of the Kardex is important with details of consults, special tests, etc. It is vital for continuity of patient care for the Kardex to be kept up to date. The Kardex needs to be filled out on the back, and also for the initial fluids, vent settings, meds, vitals, etc. every time a patient is admitted. This contains all pertinent patient information from the time of admission

13

until discharge. The Kardex is filled out and updated daily. Write your plans on the Kardex so that any subsequent caregivers know the patients plan of care. DAILY BABY You will be oriented to the Daily Baby computer system on your first day by an NNP/PA. Notes need to be completed before you leave in the evening. You should not have to stay past sign out to do this. You should be able to complete notes during the protected time from 1700-1900. If notes are not done by this time, let the NNP/PA, fellow, attending know so that they can cover any questions, emergencies while you are completing your notes. Please update all lab data and please keep your event codes updated on a daily basis. This is crucial for an appropriate and correct discharge summary to be generated. Your note must be accurate as it is a legal document. 15After you finish your note, the attending will co-sign it electronically, print and sign it, and it will be placed in the patients chart within 24-48 hrs. It is your responsibility to read the note you have written and sign it. Reading your note will give you an idea of whether or not what you have been entering as data makes sense. Good charting is important for patient communication and care. CONSULT SERVICES When consulting a subspecialty service, call them before rounds so that they may come by in a timely manner. Interns and residents are encouraged to make the call to the subspecialty service. Have the patients history on hand with all pertinent information to present. Also, remember that if you are expecting a subspecialty consult/progress note, they may sometimes write it in the chart or place it in powerchart. Be sure to check your patient charts so that you do not miss an important note from the consultant. COMMUNICATION WITH FAMILIES Each family should be contacted within four hours of the babys admission to the NBICU. Their phone number is located in the Daily Baby record, or the nursing cardex by the patients bedside. You may walk over to (or call) L&D recovery to update the family. There should be contact with the family by the primary house-officer/NNP/PA at least every 1-2 days. You will be asked on rounds when family contact has occurred. MAKE SURE TO CONTACT FAMILIES IF THERE IS ANY CHANGE IN THEIR BABYS STATUS. The attending is responsible for contacting the referring physician. However, if the physician calls and the attending is not available, feel free to talk to the referring physician. Care conferences are scheduled for each patient at 30 days of life and each month thereafter until discharge. Each house officer should make every effort to attend care conferences on patients they are covering. CONFIDENTIALITY Patient confidentiality is your professional responsibility. The NICU beds are close together so please be aware of people and your surroundings when discussing patients. Parents are the only people to receive information on their infant. Be aware of HIPAA which stands for the Health Insurance Portability and Accountability Act. The Federal Department of Health and Human Services issued HIPAA regulations to protect the confidentiality of personal health care information effective April 14, 2003. Protected health information is defined as individually identifiable health information maintained or transmitted by a covered entity in any form or medium and includes: demographic information collected from an individual medical history information relating to the past, present or future physical or mental health or condition of an individual that is identifiable the provision of health care to an individual or the payment for the provision of health care physical examinations, blood tests, x-rays other diagnostic and medical procedures Privacy standards within HIPAA limit the use and disclosure of health information; restrict most disclosures of health information to the minimum intended purpose; establish new requirements for access to records by researchers; and protect the confidentiality and integrity of health information.

14

TEACHING AND CONFERENCES

All of the following are mandatory except Neo Grand Rounds on Tuesdays and Daily Attending Sign-out:

TIME 0700 - 0900

MONDAY Receive checkout from night team, gather numbers, examine patients

TUESDAY Receive checkout from night team, gather numbers, examine patients Peri/OB Conference (Tully) ROUNDS ROUNDS XRAY Rounds Neo Rounds (Cibola) Teaching, family care conferences, notes, patient follow-up, etc Attending/fellow sign-out Resident completion of notes (do not need to attend deliveries) Sign-out

WEDNEDSAY Receive checkout from night team, gather numbers, examine patients

THURSDAY Receive checkout from night team, gather numbers, examine patients

FRIDAY Receive checkout from night team, gather numbers, examine patients

0815 - 0900 0900 - 0930 0930 - 1130 1130 1200 1300 - 1700 Teaching ROUNDS XRAY Rounds Teaching, attend all deliveries, family care conferences, notes, patient follow-up, etc Attending/fellow sign-out Resident completion of notes (do not need to attend deliveries) Sign-out

Teaching ROUNDS XRAY Rounds Teaching, family care conferences, notes, patient follow-up, etc Attending/fellow sign-out Resident completion of notes (do not need to attend deliveries) Sign-out

ROUNDS ROUNDS XRAY Rounds Pediatric Grand Rounds (Tully) Resident Education

Teaching ROUNDS XRAY Rounds Teaching, family care conferences, notes, patient followup, etc Attending/fellow sign-out Resident completion of notes (do not need to attend deliveries) Sign-out

1600 1700 - 1900

Attending/fellow signout Resident completion of notes (do not need to attend deliveries) Sign-out

1900 2000

Each house officer is expected to give a 20 minute talk on a clinically relevant NICU topic of their choice each week of service.

NEONATAL RESUSCITATION Interns/residents should always carry a delivery pager and should attend all deliveries unless they are in continuity clinic or otherwise instructed by upper level staff. Neonatal resuscitation skills will be reviewed by the supervisory resident, NNP, or fellow. They should not go to a delivery alone with a nurse. You should be NRP certified prior to your rotation. Delivery pagers should be handed off, person to person, from one shift to the next to ensure uninterrupted and adequate delivery room coverage. In the delivery room the gestational age and potential severity of illness of the infant should dictate who leads the resuscitation. Whenever possible, for term infants, routine C-section, and preemies >30 weeks EGA who are anticipated to be relatively stable, if appropriate, the intern may be at the infants head and should run the resuscitation with the assistance of the charge nurse and upper level resident, with the NNP/PA/fellow present in a supervisory role. For infants anticipated to be unstable, preemies >28wks, the resident should be at the infants head and run the resuscitation with the assistance of the charge nurse, NNP/PA/fellow with the intern present in a supervisory role. For infants <28 weeks an NNP/PA/fellow should run the resuscitation with the assistance of the charge nurse and upper level resident. Any housestaff should be prepared to relinquish management of the resuscitation to the most skilled personnel in instances where the infant is not improving. Interns and residents should not intubate for <30 wk, <1000g preemies, or meconium in the delivery room until they have demonstrated proficiency at intubation in the NICU. Pager codes most frequently used are the following:
4000- room # term C-section, term meconium walk over to L & D 4000*911 room # emergency, term baby run over to L & D 4111 room # preemie - walk quickly over to L & D 4111*911 room # emergency, preemie run over to L & D 4444 OBSC 4333 Triage ICN3 3333 MBU 3000

15

COUNSELING FOR L&D Our service is called by the OB service daily for counseling of mothers with high risk pregnancies who are awaiting delivery. Most counseling is provided by the attending/NNP/PA/fellow on service. If as a resident/intern, the unit clerk lets you know that a mother needs counseling in L&D, you may go over and gather the maternal history and pre-delivery information to present to an NNP/PA/fellow/attending. Interns should never counsel mothers by themselves. Senior residents are permitted to counsel mothers after discussing the case with an attending/NNP/PA/fellow. A counseling note must be written in powerchart and must include the name of the person requesting the consult. ADMISSIONS When admitting a baby, it is important to stay by the babies bedside. Therefore, grab a WOW and do your orders there. Admission orders need to be filled out as soon as possible after a baby has been brought to the unit. Interns should have their orders looked over by the NNP/PA, fellow or attending. Admission note in Daily Baby needs to be filled out completely. Things that are often forgotten: maternal social history, vital signs, initial labs and CXR, length and FOC, rationale for plan, all pertinent event codes. Please be thorough. It is expected that you will also GENERATE A DIFFERENTIAL DIAGNOSIS AND PROBLEM LIST for the admitted infant. Explain your rationale for your assessment and plan. A Ballard exam needs to be done on every infant admission with unclear dates, and placed in the patients chart. There is one for females and one for males. The prenatal and maternal history, maternal labs, the circumstances of labor and delivery and the resuscitation needs to be investigated and recorded in the computer and on the Kardex. This information is usually gathered after the resuscitation from the mothers chart in L & D. If there is missing information, go back to L & D and talk to the OBs or read the maternal chart. This is the best time to get the information and it is important for patient care. FORMS Growth charts are filled out on each patient by the nurses, with weight, length and FOC being followed. Remember to look at the growth chart every few days to see your patients progress, and to check if the FOC is rapidly enlarging, or not changing. TPN forms are filled out daily and need to be sent to the pharmacy no later than 12:00pm. ECHOS must be ordered in powerchart and you need to specify a clear reason i.e. ECHO to R/O PDA in a premature infant. When you pre-round, if you think your baby has a PDA and needs an ECHO, have a NNP/fellow/attending confirm your exam. Order the ECHO before rounds. You do not need to call the cardiologist for routine PDA ECHOS. In an emergency, the attending neonatologist will contact the cardiologist. Preliminary ECHO results are typically faxed to the unit and can be found in the front area outside of the front team room. Powerchart NICU Quirks Change infants weight q wed and prn. Ad Hoc /inpt /weight/ dosing wt

All TPN/PPN/IL have a start time of the date written for 23:00 and stop time of the following day at 23:00. Include in order comment section the total fluid plan (ie 140ml/kg/day = 8.5ml/hr including _____ ( TPN/IL only) or (TPN/IL/feeds) as well as any special supplements. Feedings o Formula (Floor stock) include ml /feed and frequency and nipple or gavage o Can put in order comments of the formula order to use EBM preferentially. o Simply Thick is a dietary snack o Nursing dietary order for nippling orders, or special feeding orders o If a formula is not listed under formula (floor stock), put it under formula with the calories/ounce and approximate 24 hour volume. It will be mixed in the formula room. Medications o require mg/kg/dose as well as total dose in each order o Use Neofax as your reference, plus our pharmacists o Put doses of antibiotics in daily baby event codes o Weight adjust medications on Wednesdays Respiratory:

16

o o o o

Modify orders unless changing mode of support, ie vent to CPAP Optiflow/Vapotherm = HFNC , and CPAP are under RT oxygen CanuPAP (cannula with a rate) is RT Vent and chose NI (PC) RA trial has an order

Nursing misc. task (dont use nursing communication) o tasks can be charted (ie things like OK to use PICC or Discontinue UAC) Other orders in powerchart to use: o Umbilical line order o PICC line (central line care ) o Orogastric tube to gravity or suction etc .. ( not the gavage feeding tube) PICC lines Put in by NNP/PAs, attendings, fellows or member of PICC team. Fluids for PICCs need heparin. We do not draw labs off of PICCs. If evaluating a pt with a PICC for sepsis, obtain blood cultures x 2, peripheral + PICC.

INTERIM SUMMARIES When you leave service, a computerized interim summary needs to be completed. Ask an NNP/PA how to do this. DISCHARGES An accepting physician for a transfer or a follow-up physician of the parents choice must be identified and communicated with prior to discharge. If a patient is being transported to another hospital, chest x-rays and growth charts need to be copied write an order for this to be done. You may need to call radiology to get this done. All follow-up appointments must be scheduled prior to discharge and all involved subspecialty services must be notified that the baby is being discharged. All eye exams, head ultrasounds, hearing tests should be done prior to discharge. Plan ahead. Discharge Summary forms are filled out by the nurse, HO or NNP prior to discharge. A Daily Baby discharge summary needs to be completed, corrected for any changes, event codes filled in and logged out, printed and signed by the NNP/HO and attending. A brief paragraph summarizing the patients course leading to discharge is entered. You send two copies of the discharge summary with the family (one for them, and another for the follow-up physician) AND fax a copy of the summary to the primary follow-up physician. Prescriptions should be given to a family before discharge and they need to have it filled at a nearby pharmacy or drugstore before leaving the hospital. Parents may desire a circumcision prior to discharge. This can be done by the houseofficer if they have been trained, or you can call upstairs to the Newborn Nursery and see if anyone is available to do one. This is an elective procedure and sometimes the unit is too busy for it to be done. The parents then must call their follow-up physician to arrange for it to be done as an outpatient. It can be done in the Peds Urgent Care Clinic as an appointment. See Discharge Checklist in subsequent section of manual. PROCEDURE NOTES AND CONSENTS A note needs to be entered into Daily Baby for all procedures, then printed out and signed. The attending does not sign the procedure note. It is advisable to keep a record of all procedures that you do in New Innovations; it will be needed for later medical licensing purposes. Parental consent (the forms are located near the ward clerk desk) is required for lumbar punctures, PICC lines, transfusions, etc. They need to be witnessed. Phone consent is permitted. MEDICATION ORDERS Double check your calculations. Orders for medications, blood products and fluids need to be written in mg per kilogram per dose or per day as well as the total dose (i.e. For a 3 kg baby: Cefotaxime 50 mg/kg/dose IV q8 hrs = 150 mg IV q8 hrs). The reference book used for our unit is the Neofax. You will be asked to re-order meds about once a week on your patients. Be sure to weight adjust your medications if the infant has gained substantial weight. DEATHS If a patient is critically ill, or death is expected, make sure that the family can be located at all times.

17

Ask the ward clerk for the death packet and release form. These need to be filled out when a patient dies. It has a checklist, but ask a NNP/senior HO if you are unsure how to fill it out. The family needs to be asked if they want an autopsy before the Office of the Medical Investigator (OMI) is called. There is a Grief Binder in the far left upper cabinet that you may look through that has helpful resources. At the same time that OMI is called, call Medical Records at 2-0478 Monday-Friday 8:00am-4:30pm or at 20470, 2-9136 or digital pager 951-2650 in the evenings and weekends. Medical Record Staff will immediately come to the floor to get the critical portions of the record needed for scanning so that this information will be available in Powerchart. Medical Records staff will return these portions of the record to the NNBICU so that the entire chart can go to OMI when the body is picked up. OMI will pick up the body after the family has left. There is a funeral list that you give to the family and ask them to figure out which mortuary they want to pick up the body from OMI. There are rare circumstances (i.e. with Navajo families) in which the baby can be released to the family and taken home for ceremonial purposes. OMI needs to be informed of this and consent given to release the body to the family. The parents can drive with the body along with a written note from the NNP/MD of the circumstances surrounding the infants death. Before OMI comes to take away the body, a detailed death summary (click on discharge summary on Daily Baby) must be entered into the computer describing the events leading to death. Indicate time and cause of death, whether autopsy was granted, refused, and whether the body was released to OMI. If the parents desire a grief counselor, there are counselors available at OMI. OMI Grief Services division 22485 or 2-3397. Special Delivery Program Our special delivery program offers comprehensive prenatal consultation and support, partnered with Maternal-Fetal-Medicine, genetic counselors, and Pediatric sub-specialists. Those women who are known prenatally to have a fetal anomaly will have a consult in her chart in powerchart. The Special Delivery Program offers fetal diagnosis of birth defects, counseling for and information about the diagnosis, expected medical care of the infant, information on various support groups and palliative care plans when appropriate. You can find more information about this program and other helpful links at: http://hsc.unm.edu/som/pediatrics/neonatology/SpecialDeliveryProgram.shtml Pediatric Hospice: UNM Mariposa Program Sometimes in the NICU, an infant will be discharged home to hospice care. The Mariposa Program of UNM Children's Hospital is designed to assist families facing life limiting medical conditions. Mariposa offers comprehensive, compassionate care for infants, children and adolescents with life limiting conditions. The program serves not only the child, but supports the entire family, including parents and siblings. An individualized plan of care is designed to meet the specific needs, hopes and goals of each patient and his or her family. The plan addresses the medical, nursing, psychosocial, and spiritual needs of the patient and family, and is carried out by a team of highly trained professionals. The Mariposa Program emphasizes quality of life rather than length of life, and uses whatever time is available to provide spiritual and emotional support to the patient and family. Mariposa manages children in the Albuquerque area but will be happy to make contacts for the discharging team in the child's home communities. The contact information for Mariposa is Phone: (505)272-6700. Also, you can find more information about the program by going to the website: http://hospitals.unm.edu/mariposa/index.shtml Neonatology Website: Please look at the Neonatology website: http://hsc.unm.edu/som/pediatrics/neonatology/index.shtml. Here you will find a link to the NICU resident corner; this is a site for all of you with helpful PDFs, talks, etc. It will continue to be added to, updated and changed. Please look at it and let me know (jmrael@salud.unm.edu) what you think and any suggestions or additions you have are appreciated.

18

TRANSFUSION GUIDELINES The following guidelines were revised from our previous guidelines to assist in determining when to transfuse, and apply to infants who are not receiving erythropoietin (Epo). In general: 1. A central hematocrit should be obtained on admission. No further hematocrits should be obtained unless specifically ordered. Outside of rounds, transfusions should generally only be considered if acute blood loss of 10% associated with symptoms of decreased oxygen delivery occurs, or ordered if significant hemorrhage of >20% total blood volume occurs. In term and preterm infants, a transfusion should be considered if an immediate need for increased oxygen delivery to tissues is clinically suspected. Currently, there is no single, specific test available for infants to test the need for oxygen delivery.

2.

3.

Central measurements of hemoglobin or hematocrit are preferred; alternatively, heel stick measurements may be obtained after warming the heel adequately. An infant meeting the criteria below should not automatically be transfused. Transfusions can be considered for the following: 1) For infants requiring moderate or significant mechanical ventilation, defined as MAP >8 cm H2O and FiO2 >0.40 on a conventional ventilator, or MAP>14 and FiO2 >0.40 on high frequency ventilator, transfusions can be considered if the hematocrit is 30% (hemoglobin 10 gms/dL). 2) For infants requiring minimal mechanical ventilation, defined as MAP 8 cm H2O and/or FiO2 0.40, or MAP<14 and/or FiO2<0.40 on high frequency, transfusions can be considered if the hematocrit is 25% (hemoglobin 8 gms/dL). 3) For infants on supplemental oxygen who are not requiring mechanical ventilation, transfusions can be considered if the hematocrit is 20% (hemoglobin 7 gms/dL), and one or more of the following is present: 24 hours of tachycardia (heart rate >180) or tachypnea (RR >60); a doubling of the oxygen requirement from the previous 48 hours lactate 2.5 mEq/L or an acute metabolic acidosis (pH<7.20); weight gain <10 grams/kg/day over the previous 4 days while receiving 120 kcal/kg/day; 4) For infants without any symptoms, transfusions can be considered if the hematocrit is 18% (hemoglobin 6 gms/dL) associated with an absolute reticulocyte count <100,000 cells/L (<2%), or if the infant will undergo major surgery within 72 hours. Infants should be transfused with 20 mL/kg PRBC (divided into 2 10 ml/kg aliquots given 4 hours apart) unless the Hct is >29%. 20 mL/kg volume could also be used if significant phlebotomy losses are anticipated in smaller infants with Hct>29%. For infants receiving Epo, considerations to the above guidelines should be made regarding the rate of decrease in hemoglobin or hematocrit, the infants reticulocyte count, the postnatal day of age, and the overall stability of the infant. References 1. Alverson, Clinics in Perinatology 1995;3:609-25. 2. Bell ED et al. Pediatric Research 2000;47:389A 3. Bifano, Pediatric Research 2001;49:311A 4. Bifano et al, Pediatric Research 2002;51:325A 5. Alkalay et al, Pediatrics 2003;112:838-45

19

SCREENING AND PROPHYLAXIS RECOMMENDATIONS EYE EXAMS These are performed by our pediatric ophthalmologist. The charge nurse will help arrange these exams. She records her exams in powerchart. Eye exam criteria: 1. All infants 1500 gm OR 30 wks 2. Infants (1500-2000 grams or >30 weeks with unstable course) as ordered by attending neonatologist; 3. TORCH infections, congenital anomalies, etc.; performed ASAP-call Ophthalmology directly 4. Timing of first exam: 23-27 wks at birth 31 weeks corrected age 28 -32 weeks at 4 weeks of postnatal age Follow up exams per ophthalmology recommendations. Exam to be done if baby to be transferred prior to time of eye exam.

5. 6.

HEAD ULTRASOUND All infants 30wks gestation, 1500g, will have a screening head ultrasound to rule out intraventricular hemorrhage at 7-10 days Infants born at 1000g need a repeat HUS or MRI at 36 weeks post-menstrual age or prior to discharge o The attending pediatric radiologist performs these on Tuesdays and Thursday unless it is emergent Remember to order the head ultrasound the day before it is needed. HUS may be performed earlier with TORCH infections, HIE, congenital anomalies, or at the discretion of the attending, depending on the infants clinical situation Infants with Gr. 2 or greater IVH will have a repeat study one week later, then follow up studies as clinically indicated (i.e. enlarging FOC), or prior to discharge HEARING SCREEN All babies will have a hearing screen prior to discharge Risk factors for associated sensorineural and or conductive hearing loss include: family history of hereditary childhood sensorineural hearing loss, TORCH infection, craniofacial anomalies, birthweight <1500g, hyperbilirubinemia requiring exchange transfusion, ototoxic med exposure, bacterial meningitis, low Apgar scores, prolonged mechanical ventilation, and syndromes associated with hearing loss It is important to document a failed or referred hearing screen on the discharge summary so that the primary care MD is aware of the need for follow-up BONE LABS Infants born at 30 weeks, on chronic diuretic therapy, prolonged NPO/ICU course or long term TPN use are at risk for osteopenia of prematurity. They should have calcium, phosphorus and alkaline phosphorus levels measured at one month of age and then every 2-4 weeks until discharge. Supplementation with Tribasic is recommended for alkaline phosphatase levels >500 or neutrophos with phosphorus <5. TPN LABS Patients on chronic TPN without enteral feeds are at risk for TPN cholestasis. Check LFTS at one month of age if the infant is still on TPN. They should be checked every two weeks thereafter. SYNAGIS (RSV Prophylaxis) RSV season varies from year to year, depending on the documentation of active cases.

o o

CLD (Chronic Lung Disease) <2 y/o : Synagis at the start of the season Premature, no CLD <28 wk Synagis if 12 mos at start of season 29-32 wks Synagis if 6 mos at start of season 32-35 wks Synagis if 6 mos at start season with *risk factors present *Risk factors that increase risk of RSV infection:
- passive smoke exposure - school age siblings - birth within 6 months before onset of RSV season - two or more individuals sharing a bedroom - multiple births - daycare attendance

20

HEPATITIS B VACCINE Term infants born to HBsAg(-) Mother New recommendation to give at birth Term infants born to HBsAg(+) Mother Hepatitis B vaccine 0.5 ml and Hepatitis B Immune Globulin (HBIG) 0.5 ml are given concurrently within 12 hours of delivery. Term infants born to HBsAg(?) Mother Maternal testing is recommended as soon as possible. Hepatitis B vaccine should be given within 12 hours of delivery. HBIG should be given as soon as possible or within 7 days of delivery if mothers HBsAg is (+) or still unknown. Preterm infants born to HBsAg(-) Mother Preterm infants who are <2 kg at birth should be given dose 1 just before hospital discharge If >2 kgs, give at birth Preterm infants born to HBsAg(+) Mother Hepatitis B vaccine and HBIG are given concurrently within 12 hours of delivery. Vaccine is repeated at 1 month as first vaccine and again at 2 and 6 months. Preterm infants born to HBsAg(?) Mother Maternal testing is recommended as soon as possible. Hepatitis B vaccine should be given within 12 hours of delivery. HBIG should be given as soon as possible or within 12 hours of delivery if the infant is <2 kg, if mothers HBsAg is (+) or still unknown. Hepatitis B Immune Globulin (human): 0.5 ml IM in anterolateral thigh Hepatitis B Vaccine: Energix-B 10mcg (0.5 ml) or Recombivax HB 5mcg (0.5 ml) IM Breastfeeding of the infant by an HBsAg positive mother poses no additional risk for acquisition of hepatitis B infection by the infant AAP 2003 Red Book, p117.

(BPD) ECHOCARDIOGRAMS All infants with moderate to severe chronic lung disease and all infants born at 26 weeks gestation should have an echocardiogram performed monthly until discharge, to screen for RVH All infants receiving one week of steroids should have echo performed to screen for cardiomyopathy ABNORMAL NEWBORN SCREENS THYROID: if first two State screens are abnormal, compatible with sick eurothyroid syndrome, repeat one in the UNM lab If still abnormal, obtain an endocrine consult CAH: Check Na/K, repeat NBS for CAH PKU: Repeat

21

TPN CHEAT SHEET Glucose infusion rate (GIR) in mg/kg/min: (% dextrose solution) x (IV rate in cc) (weight in kg)x (6) Dextrose water (DW) calories (kcal per cc) D5 D7.5 D10 D12.5 D15 IL20%=2 kcal/cc Formula (1 oz = 30 cc) 20 cal/oz = 0.67 kcal/cc 22 = 0.7 24 = 0.8 26 = 0.87 INCREASING AN EXISTING GLUCOSE CONCENTRATION Need to know: a) Current glucose concentration being infused. b) What you want to increase the concentration to c) What concentration of glucose you are going to use to increase or decrease the current fluids concentration. Equations 1. Concentration Desired Current Concentration Concentrate Current Concentration 2. Concentrate Desired Concentration Concentrate Current Concentration = = % concentrate or diluent to be used % current fluid to be used 0.17 0.26 0.34 0.43 0.51 D17.5 D20 D22.5 D25 D27.5 0.60 0.68 0.80 0.85 0.94

Example: 2.0 kg infant currently receiving D20W at 6cc/hr and want to increase it to D25 using D50 as additive: 1. 25 20 = 0.17 50 20 2. 50 25 = 0.83 50 20

If you want to Y-in the D50, then 17% of the 6cc/hr should be D50 and 83% of the 6cc/hr should be the D20. Therefore the D50 will infuse at 1cc/hr and the D20 will infuse at 5 cc/hr. Double check your answer by calculating GIR for what the desired fluid would give and then the combination of fluids: 1. 2. (25)(6)/(2)(6) = 12.5 mg/kg/min (20)(5)/(2)(6) + (50)(1)/(2)(6) = 12.5 mg/kg/min

UAC and UVC PLACEMENT You will need: Procedure Cart mask, sterile gloves, sterile gown, sterile OR towels or clear drape, stopcocks Umbilical vessel catheterization tray (disposable) ask nurse to get out of pyxis Normal saline flush with heparin ask nurse for this Procedure light Generally, we use 3.5 Fr catheters for UAC placement, and 5.0 Fr catheters for UVC placement. For an infant 1500g, a 3.5 Fr catheter may be necessary for the UVC. Ask the attending what size catheter he/she prefers. Both size catheters are found in an umbilical vessel catheterization tray.

22

UAC placement: * In our unit, high UAC lines are usually placed. o High line: A. Shoulder to umbilicus + 1 cm + length of umbilical stump B. (3 x birthweight in kg) + 9 + length of stump o On x-ray a high UAC should be between T6 and T9. o Low line = Birthweight (kg) + 7 o On x-ray a low UAC should be between L3 and L4. UVC placement: o (UAC length x 0.5) + 1 o On x-ray the UVC should be above the diaphragm. Confirm placement of umbilical lines via AP and lateral babygram. Write a procedure note in Daily Baby. Clean up after yourself and be sure to dispose of all sharps properly. Document your procedure in your log. ENDOTRACHEAL INTUBATION WEIGHT GESTATIONAL AGE < 1000g <28 weeks 1000 - 2000g 28 - 34 weeks 2000 - 3000g 34 38 weeks 3000 4000g >38 weeks 1. SIZE OF ETT (mm) 2.5 3.0 3.5 3.5 4.0 LIP REFERENCE (6cm + wt in kg) 7 8 9 10

Use Miller 0 blade for preterm infant and 1 blade for term infants.

Put on gloves. Select appropriate ETT size and insert stylet, making sure it doesnt protrude past end of ETT. 2. Place infant in sniff position and provide oxygen to pre-oxygenate. 3. Insert laryngoscope with left hand while stabilizing infants head with right hand. Insert gently to right of midline and while advancing move it midline, deflecting the tongue. 4. Advance blade into vallecula and lift blade upward bring epiglottis into view. 5. Suction secretions if they are obstructing your view. Ask for cricoid pressure from RT/nurse if cords are anterior. 6. Once cords are visualized keep eyes on them do not look away ask for suction or the tube if needed. 7. Insert ETT through cords gently do not force the tube - with right hand while maintaining visualization of vocal cords. 8. Withdraw laryngoscope and remove stylet from ETT while holding the ETT against the roof of the mouth. 9. Confirm intubation with auscultation for bilateral equal breath sounds and check lip reference to adjust tube to proper depth. Do not let go until the RT secures the tube with tape. 10. Intubation attempts should be limited to 20 seconds and should be aborted when oxygen saturations drop below 80% or the heart rate drops. 11. Verify ETT placement with AP chest xray.
* Remember to write, print out and sign a procedure note in Daily baby for this procedure.

23

COMMONLY USED NICU DRUGS Please refer to neofax for any questions INDOMETHACIN PDA Closure Dose (mg/kg) Age at 1st dose 1st < 48 hrs 0.2 2 7 days 0.2 > 7 days 0.2

2nd 0.1 0.2 0.25

3rd 0.1 0.2 0.25

In <1000 g infants, give q24 hrs for first course, and q12 hrs if it is their second course. For remaining infants, give q12 hrs. * You must discuss and confirm dose and interval with attending.

EPO

Recommendations for infants receiving TPN: 200 units/kg/day, added to TPN. Begin dosing when infant is receiving protein. IV administration (if not added to TPN) to run over at least 4 hours, use protein-containing solution to dilute. Recommendations for subcutaneous administration: 400 units/kg given three times a week. Begin dosing at 7 to 10 days of life, or when IV access is gone. Enterally fed infants also need their friends (vitamins!) o Vitamin E 15 IU PO QD / 25 IU PO QD in term infant o Folate 50 mcg PO QD o Iron 4-6 mg/kg/day Recommendations for length of treatment: Continue dosing until 34-36 week corrected gestational age.

Contraindicated in infants with thromboembolic disease, hypertension or seizures

CAFFEINE

Load with 10 mg/kg IV/PO and then start maintenance 2.5 mg/kg/day divided BID. Anticipate treating until 34 weeks EGA
*UNM uses caffeine base (10mg/ml) = caffeine citrate (20mg/ml).

SODIUM SUPPLEMENTATION The daily sodium requirement for growth in premature infants 32 weeks gestation is 4 to 5 mEq/kg/day during the first 4-6 weeks after birth. Sodium supplementation should start after the initial weight loss (4-6 days after birth) and continue until the infant is 4-6 weeks old (discontinue at 4 weeks in larger, healthier preemies, at 6 weeks in for the sicker, smaller ones). Generally, 2 mEq/kg/day of supplementation divided into q12h aliquots added to milk is sufficient and safe.

SURFACTANT

Infasurf 3 ml/kg/dose per ETT Standardized Acute Care Drip Medications Dopamine o Standard concentration 1600mcg/ml: (_____mcg/kg/min)(_____kg)(60) ___________________________________ 1600 mcg/ml High concentration 3200mcg/ml: (_____mcg/kg/min)(_____kg)(60) ____________________________________ 3200 mcg/ml = _____ml/hr

= _____ml/hr

Dobutamine o Standard concentration 2000mcg/ml: (_____mcg/kg/min)(_____kg)(60) ____________________________________ 1600 mcg/ml = _____ml/hr

24

High concentration 4000mcg/ml: (_____mcg/kg/min)(_____kg)(60) ____________________________________ 3200 mcg/ml = _____ml/hr

Typical NICU rates are 0.1-1.0 ml/hr. When writing drip order: Titrate drip to keep mean blood pressure between: ____ and ____mm/Hg.

25

NBICUDISCHARGECHECKLIST BeginningatAdmission: []Assessanyfamilyspecialneeds,social situationwhichmayaffectd/c Bedsideteaching(CPR,meds,feedings,safety) []startedDate:_____ []completedDate:_____ FollowupMD []Identified:_______________________ []Calledon:_________by:__________ []FamilyappliedforMedicaidYNN/A By3WeeksPriortoD/C: []D/CSummaryStarted []UpdatedDates:______________ []Completed: []Urgeparentstogetpertussisvax (e.g.,shuttletofreecliniconSpruce) By2WeeksPriortoD/C: []Circumcision?YNN/A []Askparents(12weekspriortoD/C) []Completed:_____ []D/CHUSorMRIYNN/ADate:_____ []BPDEchoYNN/ADate:_____ []HepB []Immunizations:2mo:_____4mo:_____ []Synagis:YNN/Adates:#1____#2____ []Eyeexam:Date:_____Results:_____________ []F/Uneeded?YNdate:_____ DuringLastWeekPriortoD/C: []Parentsnotifiedofdischargedate []ParentsroominYNN/ADate:_____ []ParentsneedWIC?YN []Prescriptionswritten []Needpriorauthorization? []Filled []Medteachingcompleted []HomeEquipment/Nursingneeded?YNWhat:___________________________________ []Orders/requeststoD/CPlanners []Delivered []Familyteachingcompleted []CarSeatTrial:PassFailDate:_____ []Carseat@bedside23dayspriortod/c []HearingScreen:Date:_____Results:R___L___ []Problems/diagnosesreviewed/updatedforD/C []DepartProcessinPowerChartStarted []Completed []CopiesofD/CSummary,growthcharts,pertinentconsultstoparents IfMoreExtensiveF/UisNeeded: []F/UConsultingService:__________________ []OKford/c? []ApptsforF/Urequested/made Date:_________Who:___________ Where:_____________ []Anyspecialneeds/info []F/UConsultingService:__________________ []OKford/c? []ApptsforF/Urequested/made Date:_________Who:___________ Where:_____________ []Anyspecialneeds/info []F/UConsultingService:__________________ []OKford/c? []ApptsforF/Urequested/made Date:_________Who:___________ Where:_____________ []Anyspecialneeds/info []OtherF/Uappointmentsneeded

26