INTRODUCTION

NICU 220-6210 Lab 220-6550 X-Ray 220-6147 X-Ray Report 220-8266
MRI/CT Report 297-6790 Newborn Nursery 220-6226 Special Diagnostics Lab 220-6256
Infant Apnea Program 220-6257 Discharge Planners 220-6218 Labor & Delivery 220-6220
Children's OR 220-6236 Anesthesia 220-8145 PAR 220-6501 Speech Pathology 220-8288
Neonatology Office 220-6260 PICU 220-6310

Welcome to the NICU at Children's Hospital. We are a regional perinatal center serving primarily the greater St. Paul area, as well as western Wisconsin. Although most of our babies are delivered at United/Children's Perinatal Center, about 20% of our babies are transported in from other hospitals. We provide level II and level III neonatal diagnostic and supportive care including mechanical ventilation, high frequency ventilation, cardiac catheterization, cardiac surgery and pediatric surgery. This does not include ECMO; for this procedure, patients are referred to the University of Minnesota or Minneapolis Children's Medical Center. In addition, we run a regional Infant Apnea Program and staff the NICU Follow-Up Clinic.

GOALS OF RESIDENT ROTATION

• Understand pathophysiology and treatment of common newborn diseases;
• Develop procedural skills in newborn resuscitation and emergency intervention;
• Recognize clinical and laboratory signs of a sick newborn and develop appropriate treatment plans;
• Recognize common congenital malformations and syndromes;
• Identify high-risk obstetrical factors.

ROLE OF FELLOW AND ATTENDING

In general, both the fellow and staff attending will make daily rounds. On occasion, rounds will be under the direction of the fellow. No significant change in plans made during rounds should be made without consultation with the fellow or attending. The on-call fellow or attending should be notified of all admissions (day or night), particularly those requiring mechanical ventilation or consultation. The fellow is available for immediate supervision of all procedures.

ROLE OF NURSE PRACTITIONERS

Neonatal nurse practitioners are nurses specially educated in neonatal resuscitation and stabilization. They function as care providers under the guidance of staff physicians. They have their own patient team, write orders and do daily notes. Most are quite skilled at common NICU invasive procedures. They are present 24 hours per day to assist you in attending all deliveries, providing daily patient care and performing procedures as needed. In addition, they are responsible for all outside transports. You should work with them as experienced caregivers who can share with you a lot of practical experience, as well as technical expertise.

ROUNDS

Residents should arrive at the NICU each morning in time to be updated on their patients by the previous on-call team and nursing staff, examine their patients, and prepare for rounds. It is expected that you will have examined all your patients prior to daily rounds. Rounds commence at 9:00 AM in the radiology department where x-rays are reviewed prior to formal rounds in the NICU.

During daily rounds (09:00 - 12:00), a nurse practitioner will direct care of patients and respond to critical laboratory values. The practitioner will consult with the appropriate resident during rounds regarding any major change in a patient's condition. Following rounds, it is the responsibility of the resident to check with the practitioner regarding any changes in his/her patients' management or condition, particularly in regard to plans made during rounds. Similar communication should be made following noon conference when each resident will assume responsibility for his/her patients.

ON CALL

Residents are on call every third night, beginning at 8 a.m. The post-call resident will sign out his/her patients to the on-call resident following noon conference. The pre-call resident will sign out his/her patients to the on-call resident at 4:00 PM. At 4:00 PM, the on-call resident will assume responsibility for all patients for the remainder of the day and make sign-out rounds with the nurse practitioners. The on-call nurse practitioners and resident will make evening rounds on all intensive care status patients and order any appropriate AM labs. The on-call resident is not necessarily responsible for all patients in the NICU; responsibilities can be divided with the on-call nurse practitioners.

One nurse practitioner and the on-call resident will attend all deliveries. It may be advantageous to split night call from midnight to 8:00 AM. This 7-8 hour period can be evenly split between the neonatal nurse practitioner and on-call resident. All calls during the designated period of time can be directed either to the nurse practitioner or on-call resident, ensuring that one will not be interrupted for routine labs.

DELIVERY ROOM

The nurse practitioner, fellow, or staff neonatologist will accompany residents to all deliveries. The resident should introduce himself/herself to the attending physician and parents in the delivery room. If intubation is anticipated for establishment of the airway or suction of meconium, it is helpful if this is explained ahead of time. Whatever is done or not done in the delivery room should be noted on the infant's chart. The attending physician of any infant who is transferred to the normal nursery after requiring significant resuscitation should be notified

NOTES

Daily progress notes should be written each day for each patient by the resident or nurse practitioner. In addition, a procedure note describing type of procedure, indication, size catheter or tube, and outcome of procedure should be written by the person performing the procedure; there is a special stamp in the Unit to use to simplify the procedure note. A note should be written any time a major change in therapy is undertaken, including any resuscitation or postoperatively.

Transfer notes should be written for all infants transferred from the NICU to the Newborn Nursery, Pediatric wards, or the Transitional Care Unit. Infants transferred to the TCU also need complete orders written, stating all the current medications that they are receiving. Infants on Observation Status should have a brief note indicating the reason for observation in the NICU and any changes in the infant's condition during transition; the infant's family physician should be informed when an observation status infant is transferred.

PATIENT ASSIGNMENT

Admissions will be assigned to the on-call resident or clinicians by the fellow. In general, family practice residents and medical students should not be assigned mechanically ventilated infants. Each pediatric resident is responsible for reviewing the daily management plans for patients assigned to the family practice resident or medical student. When there is a discrepancy between the number of patients carried by each resident or practitioner, the NICU fellow will reassign patients.

OTHER ADMISSIONS

All infants requiring intensive care who are less than one month of age are admitted to the NICU. In addition, all infants who are less than one year of age and who are home monitored through the Infant Apnea Program are generally admitted to the Apnea Diagnostic Center. If these infants are critically ill, requiring invasive monitoring and mechanical ventilation, then they are admitted to the PICU until such monitoring is no longer required.

CONSULTATIONS

Only the attending neonatologist or fellow can decide to obtain a subspeciaty consult, and choose the designated consultant. (There are no "generic" surgery, neurology, or cardiology consults; so the specific physician consultant should be designated.) Parents should also be notified of any consults, major test results, or significant changes in their infant's condition.

TRANSFUSIONS AND INFORMED CONSENT

Parents are to be informed prior to any blood product transfusion (not only PRBCs, but also FFP, cryoprecepitate, etc.). The transfusion forms we use imply that, when you initial the form, you have obtained informed consent for the transfusion; once informed consent is obtained, you do not need to obtain informed consent for each transfusion (unless that is an issue with that family), but out of courtesy, the family should still be informed that a transfusion will take place. Directed donor transfusions are dependent on the family contacting the Children's Hospital blood bank for the initial screening process and then following up by donating blood at the American Red Cross. The appropriate forms as well as additional information is available in the Unit. This process takes a minimum of 72 hours excluding weekends, therefore the family should be aware that, at times, transfusion of random donor blood may need to occur before directed donor blood is available.

Please also see the "Transfusion Protocol" and "Erythropoeitin Protocol" in later sections.

CONFERENCES

You will receive a schedule of didactic conferences that will start at 12:30 on the designated days. Once a month there will be a Mortality Conference where all NICU and delivery room deaths will be discussed; consultants are invited, and if there was an autopsy or other pathology specimens , they will be shown and discussed by Pathology. Occasionally there will be additional conferences, such as the Pulmonary Conference, Grand Rounds or Perinatal Rounds (depending on the topic), that you will be encouraged and expected to attend.

OTHER

• Please wash your hands before examining patients. "Universal Precautions" are observed in this unit.
• Don't ignore monitor alarms. If you do not know how to answer an alarm, please notify an infant's nurse so that the appropriate alarm condition can be documented.
• There is no dress code for the NICU. However, parents and staff appreciate a neat appearance. If you want to attend deliveries, then you should wear scrubs.

CLINICAL RESOURCE NURSES (CRNS)

CRNs function as "head" or "charge" nurse for each shift. The CRNs are here to help with organization and problem solving. They participate in daily rounds. Please inform the CRN of any admissions or transports so they may respond accordingly. CRNs are an invaluable source of practical information for day-to-day patient management. Do not hesitate to ask questions.

DISCHARGE PLANNERS

Discharge Planners fill a relatively new role in the NICU, that of organizing the discharge and follow-up of the most complicated NICU patients. They coordinate follow-up appointments, deal with various insurance and medical assistance issues, and also are involved with education of families including CPR training. They also coordinate transfers back to referral hospitals or to our own Transitional Care Unit.

ORDER WRITING

To facilitate completion of orders, please note the following:

X-Rays­ When ordering any type of x-ray please write a reason for each request. If several x-rays are done in one shift for the same reason, each order needs a written reason - i.e., chest x-ray for ET tube placement. Please specify if AP and lateral views are needed, or if chest and abdomen should be included. This is also true for ultrasounds, cardiac echoes, EKGs, EEGs, CTs. Do not order a cranial ultrasound if the infant has a scalp IV.

IVs ­ All IV solutions, for peripheral or central catheters, must be reordered daily . Please try to complete TPN orders as early as possible (13:30 would be ideal) so orders may be transcribed and sent to Pharmacy.

• Specify if central or peripheral IV
• If existing IV is to be discontinued, you must indicate this
• If central line discontinued, we do not routinely culture the tip of central catheters
• When ordering TPN, make sure the order form is stamped correctly with infant's nameplate.

Medications ­ All meds must have a strength and route of administration specified. For example:

• Indicate 1/4 glycerin suppository, or an adult size will be dispensed;
• Indicate the dilution for any nebulization (1:20 is most commonly used).
• Specify mg, mcg or other dose units, not a volume.

Labs ­ There are no standing labs.

• When ordering labs, please specify time. If written for today, state time. AM labs are done at 0700. Labs that need to be done at change of hyperalimentation are at 2100.
• When attempting to access on computer, please use computer on convalescent side since it has easier access.
• If you remove any lab results from the printer, please chart on result board so they are not lost.

Pulse Oximeters and MMUs

• When ordering Oximeters, MMUs, etc., please write for length of time to be used: 12 hours, continuous
• Please do not ignore monitor alarms or assume someone else will respond. Observe the type of alarm and the state of the infant before disabling or resetting the alarm. Notify the nurse responsible for the infant, so that the alarm and event can be appropriately documented.

Orders

• Use the green tag on each chart to indicate orders have been written. If orders are STAT, please notify infant's nurse so orders may be quickly implemented. Also, pull the red tag and place on desk to facilitate quick transcription.
• If any changes are made on rounds or after examination, such as changes in ventilator settings, please notify nurse and write the appropriate order.

NEWBORN NURSERY: ADMISSION GUIDELINES

• Admission to the Newborn Nursery is limited to babies recently born at United or those who have been transferred to the Perinatal Center. Newborns are not readmitted to the Newborn Nursery for treatment of medical/surgical problems.

• The CHI Newborn Nursery is staffed as a Level I nursery; it includes a close observation transitional period of 6 hours after birth.
• After transition, the newborn is cared for as a mother-baby unit on days/evenings. (Most newborns spend the majority of their time in their parent's room.)
• Newborns requiring 24 hour care in the nursery, (e.g. "boarder" babies, those being treated for hyperbilirubinemia or unstable newborns) are staffed at a 1:4 ratio. The daily charge is higher for these newborns, comparable to other inpatient pediatric patients.
• Newborns should be at least 35 weeks for direct admission into Newborn Nursery. Newborns less than 35 weeks gestational age assessment should be initially admitted into NICU for at least 12 hours observation.
• Infants in the Newborn Nursery requiring oxygen therapy more than 6 hours should be evaluated for transfer to NICU.
• Newborns with symptoms requiring a monitor (excluding parental anxiety) are not appropriate for the Newborn Nursery.

OBSERVATION STATUS

Observation Status is a time period when a newborn is in the NICU being closely observed, but has not been admitted. This allows for appropriate assessment during a transitional time period when the infant's symptoms may resolve, allowing for transfer back to Newborn Nursery. Conversely, if the infant's symptoms persist or worsen, the infant can then be admitted to the NICU and appropriately treated. A physical exam should be completed, a progress note written, and the primary physician of the infant needs to be notified. Transfer of an Observation Status infant to Newborn Nursery needs to be discussed with the attending neonatologist, and a progress note needs to be written.

This status is appropriate for: ­ Infants < 36 weeks gestation

• Infants of diabetic mothers, including insulin dependent gestational diabetics
• Intrauterine growth retarded infants
• Infants with respiratory distress
• Infants whose mothers have chorioamnionitis

Infants on Observation Status may require some screening tests or procedures, which may include a blood sugar, cardiorespiratory and oxygen saturation monitoring, or chest x-ray. Infants requiring treatment (i.e., IV or antibiotics) should be admitted to the NICU.

Infants whose mothers have suspected chorioamnionitis:

• Mothers who receive intrapartum antibiotics for presumed chorioamninitis
• Mothers who have intrapartum fever
• Mothers who have genital tract cultures positive for Group B Strep

If infants born to these mothers are completely normal in the delivery room, they may be admitted to Newborn Nursery.

Any infant born to the above mothers who: 1) requires any type of resuscitation in the delivery room 2) is preterm or 3) is symptomatic (tachypnea, poor perfusion, etc.) should come to the NICU on Observation Status. Evaluation for sepsis should include vital sign, blood culture, CBC and platelet count. If treatment with antibiotics is required, he would then be admitted.

REMINDERS

Rounds

NICU daily rounds begin in the Radiology Department at 9:00 a.m., where x-rays and any special diagnostic procedures are reviewed. House staff and practitioners should know what studies their patients had, including cranial ultrasounds and contrast studies.

During rounds in the NICU, house staff and practitioners should discuss each patient in a problem-oriented fashion. In addition to merely reciting relevant data, e.g. weight, input and output, calories, one should interpret and attempt to give some meaning to the data. For example, if the weight is significantly increased or decreased from the previous day, does this represent a trend or does the change reflect the effect of therapy, such as diuretics. It is assumed that all patients will have been examined, their chart and laboratory values from the previous day reviewed, and any changes in clinical status discussed with the nurses before rounds. Since parents are often present during rounds, one should exercise discretion when discussing sensitive problems. This may include delaying discussion or using euphemisms.

Consultants often make rounds early and record their findings as well as recommendations on the chart (rather than speaking directly with housestaff or nursing staff). Review of Progress Notes and Consultant Forms before NICU rounds will make transfer of this information more efficient.

Rounds on convalescent patients should focus on resolution of problems leading to discharge. These problems generally include advancement of feedings, resolution of apnea, and need for diuretics and/or oxygen. House officers and practitioners should not only know intake and output, but how their patient is being fed - for example, number of gavage vs. nursing/bottle feeds. Prior to rounds, feedings should be discussed with the nurses so that recommendations can be made to maintain or advance the feeding schedule. The apnea alarm sheet should be scrutinized to determine which of the charted alarms represent significant events.

At times, the NICU staff is responsible for patients in the Newborn Nursery of United Hospital, particularly infants of maternal transfers to the Perinatal Center. These patients will be rounded on daily, either before or after rounds in the NICU.

House officers and practitioners should use formal rounds and sign-out rounds on Fridays to ensure that their patients receive continuity of care through the weekend. This includes anticipation and completion of all discharges. Weekend on-call house officers and practitioners are expected to be familiar with the problems and therapeutic plans for all patients, not just their assigned primary patients.

Discharge dates should be anticipated enough in advance so that on the day of discharge all paper work, including discharge summary, has been completed. All discharge medications should be ordered the day prior to discharge. The parents should have designated a family practitioner or pediatrician who will follow the infant after discharge. The need for a pneumogram (MMU) should be anticipated. Generally, MMU are done when an infant is nursing or bottling all feeds and is having what is thought to be only minor monitor alarms. Parents should be cautioned that sometimes a MMU is technically unsatisfactory and may need to be repeated. Also, an abnormal MMU may prolong hospitalization.

Discharge Forms

House officers and nurse practitioners do not dictate formal discharge summaries. Instead, they are asked to complete a Discharge Summary Form, which is used as a template for a discharge letter. These forms should be initiated on admission with all relevant prenatal and referral physician data inserted. One should complete the forms as if they were dictating a summary from the information on the Form. Each additional problem, including need for antibiotics, feeding intolerance, medications, or procedures should be dated and recorded. The Form should be completed before discharge so that the only information to be completed on the day of discharge is insertion of the patient's weight. This is particularly important on weekends when the responsible house officer or practitioner is off. As noted above, discharge physical exam, medications, and follow-up appointments with primary and subspecialty physicians should be scheduled prior to discharge. The completed form should be given to the secretaries in the Neonatal Medicine Office. Please sign the form so that appropriate credit can be given to the individual completing the form.

Infants who are transferred to the normal nursery from the NICU and will not be followed by the NICU staff need a Discharge Form completed. Likewise, any infant discharged home from the normal nursery needs a Discharge Form.

Off Service/Interim 30 Day Summaries

House officers are expected, at the end of each rotation, to write a detailed off-service note for each of their patients, emphasizing all problems, both current and resolved. Any anticipated changes in therapy or tests that need to be completed before discharge should be noted. Similarly, nurse practitioners will dictate an interim summary for each patient who has been in the NICU 30 days or more. This summary should also be updated every 30 days.

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