Helpful Tips

Helpful Tips for the NICU

1. Progress Notes
  1. 1. Prepare a progress note on each of your patients every morning before rounds. All progress notes need an interval history, the new weight, vitals, a physical examination, a list of current medications, and the most recent labs.
    2. This is a guideline for your Assessment/Plan section:
      1. FEN:
        Total fluid volume per kg per day, total kcals per kg per day; if on TPN, then TPN composition (you can put e.g., D10 with 4 gm/kg amino acids and 2 gm/kg/d lipids), total feeding volume, which feeds the patient is receiving (EMM, SSC, Neosure), advancing plan and goal (e.g. 15 ml q3h, advancing by 1 ml q6h to 25 ml q 3h max), how much of feedings baby took by mouth (e.g., PO 85%). Include Vitamin D supplementation. Put in the dates of all central lines and current IV access here (e.g., "UAC 6/1-6/5, UVC 6/1-6/8, PICC placed 6/8- present).
        Resp:
        Support settings for ventilator or CPAP or NC, including flow rates and Fi02; if on no support put on RA. Mention briefly significant respiratory history (s/p HFOV 6/4-6/6, surfactant, pneumothoraces, dates of mechanical ventilation and when last extubated). Include plan for next CXR and blood gas schedule if they are needed.
        CV:
        Include last echocardiogram result with date and presumed date of any repeat. Include dates and outcomes of PDA treatment (e.g., "s/p two courses indocin 6/1-3 and 6/5-7, then PDA ligated 6/10"). Include dates of pressor administration and if the baby has had a history of SVT.
        GI:
        Number of stools if important, or "normal stool pattern" OK if stooled at least once in 24 h without problems and feeding/growing with no issues. Put in history of NEC including dates of onset, treatment courses, surgeries. Note here if any reflux and if on reflux meds.
        Jaundice:
        Put in peak bili, most recent bili, dates of phototherapy. If there is ABO incompatibility or other risk factors, include those here.
        Renal:
        UOP in ml/kg/hr if important, or "adequate urine output" for feeders/growers (as long as baby had at least 3-4 wet diapers). Put in any renal US results and dates and any renal complications.
        Heme:
        Put in the last hematocrit, reticulocyte count, and platelet count with date, if done. Note any coagulopathy history. Include dates of transfusions. Include iron supplementation.
        Neuro:
        Put in date of last HUS or other imaging studies, with result, if done. Note any seizure history including meds and EEGs. For an HIE baby who was on the cooling protocol, note dates of treatment. Include dates of pain/sedation medications, particularly if drips were used (e.g. s/p morphine gtt 6/3-6/10, now on methadone wean). Include dates of last wean and next anticipated wean if a baby is on a methadone/morphine/ativan wean or is on morphine for Neonatal Abstinence Syndrome.
        Ophtho:
        Every note needs this included with the date and result of their last ROP exam and the date of their next one. If they're not a candidate for exam (>32 weeks, >1500 gm), put "not a candidate for exam," but include the category anyway.
        Healthcare maintenance/immunizations:
        Include dates of immunizations and when the baby is due for next set of immunizations. We follow the standard immunization schedule based on chronologic, not corrected age. I.e. A 2 month old should still receive standard immunizations even if only corrected to 34 weeks. (The exception is rotavirus vaccine, which is not administered in the NICU.) Also state here if the baby is a candidate for Synagis.
    3. Use spell check if you need to (isolette has 2 t's, for example). Remember your note is the main legal and medical daily document in the chart.
    4. Only use exact dates for time reference (don't put "today", "yesterday" "Monday," "next week". e.g.: rpt HUS on 4/29.) Because we write a new interval history every day, that's the one place we will use "this morning" or "last night".

1. Outline for Presentations on Rounds:
  1. 1. Patient ID “Sally is a 4 day old corrected to 29 5/7 days GA with primary problems being RDS and feeding intolerance”
    2. Interval events- notable events since yesterday’s rounds. Include # of apnea/bradycardia spells requiring intervention. Other pertinent events include procedures (e.g. chest tube placed for recurrent pneumothorax) and changes in clinical status (e.g. extubated to CPAP; hypothermic prompting rule out sepsis, etc).
    3. Vital signs- report only pertinent values to the particular patient and new trends or abnormalities
    4. Weight. Give the weight change from yesterday, % down from BW until they have regained. Also include the 7 day average weight gain/loss for babies mostly feeding and growing.
    5. Exam. Include pertinent positives and negatives as well as any changes from prior.
    6. Fluids and nutrition. State total fluids in mL/kg/day, what they are receiving (e.g. TPN of 14/3/2 at 60 mL/kg/day plus EMM at 80 mL/kg/day), and total kcal/kg/day. Give the type of fortification and additives to feeds.
    7. Respiratory support. Include ventilator settings, amount of CPAP/HHFNC and range of FiO2 in past 24 hrs.
    8. Labs and imaging. New results, including most recent blood gas. No need to read the entire CMP results, just mention the abnormal and/or pertinent values (e.g. CMP was notable for sodium stable at 132 and bilirubin of 11).
    9. Assessment and Plans. Don’t repeat the day of life and cga here. Only focus on what is pertinent for the day. The rest can stay in your note as outlined above.
    10. Go by systems: FEN/GI (what are you going to change in the TPN and/or feeds?), respiratory/apnea, CV, jaundice, Renal, ID, heme, neuro (next head US?), healthcare maintenance (immunizations) and follow-ups. Again, just the systems relevant to the particular baby.
    11. PCP: Try to identify the PCP for your patients as soon as possible after admission. We send them weekly updates, and sometimes there are insurance issues so do not wait until the day before discharge to determine the PCP. If the parents need help, our discharge planner can help them identify providers in their area.

1. Orders
  1. 1. When you write an order, notify the bedside nurse unless it was already discussed on morning rounds. The NICU nurses are busy and may not be able to check Epic in time to see an urgent order.
    2. The radiology tech needs to be paged to come to the unit for x-rays ordered after 10:30pm. Often times the RNs or HUC will help with this.
    3. The EKG tech needs to be paged to come to the unit for any EKG ordered. The HUC will help with this.
    4. The primary NICU team should be writing orders for all babies on the NICU service. If we are jointly managing a surgery patient with the Pediatric General Surgery team, it is expected to discuss the daily plan with them. You should expect to write fluid, TPN, lab, x-ray, and medication orders. There are times when it is more appropriate for that service to order a radiology study for coordination of care but be sure to confirm who will be writing the order.
    5. The primary admission Order sets you will be using are:
      1. Ped: NICU: Admission
        Ped: NICU: Micropreemie Admission (for infants <30 wks GA)
    6. Other helpful Order sets:
      1. Ped: NICU: Complex Feeding. This includes standard feeding fortification orders.
        Ped: NICU: Fever > 72hrs. This has common lab orders for rule-out sepsis, CSF labs, and common antibiotics stratified by age and weight.
        Ped: NICU: Intubation. This includes rapid sequence medications for semi-elective and elective intubations in infants with IV access. (Discuss with fellow or attending prior to administering RSI medications!)
        Ped: NICU: Hyperbilirubinemia: This includes various phototherapy methods and orders for eye shields, radiance level, etc.
    7. Please use the Transfer Patient navigator when sending a baby to the MBU or transferring from the MBU to the NICU.
    8. Discharge and transfer summary templates
      1. Discharge summary: .ipmdpednicudischarge
        Transfer summary: .ipmdpednicutx (to be used for ward or PICU transfers)
    9. TPN orders.
      1. TPN orders are now on epic. Orders are due at 1PM every day.
        To initiate TPN, go to the orderset Ped: Parenteral Nutrition: Neonatal.
        To reorder TPN for the day (without or without changes), find the TPN orders and click “reorder”. Make changes to the TPN components as you would like. DO NOT click “modify” unless you want to discontinue the current TPN immediately.
        Please ask for help from the DNCC dietitians, your seniors, or members of the AP team if you have questions on how to write TPN.
2. Procedures
  1. 1. Commonly performed procedures in the NICU include endotracheal intubations, umbilical catheterization, and chest tube placement.
    2. There is a simulation/education room in the back of the NICU that is available to all members of the NICU care team to simulate procedures. Ask a fellow, nurse, or nurse practitioner to help you if you need help.
    3. Link to umbilical vessel catheterization video: http://www.nejm.org/doi/full/10.1056/NEJMvcm0800666

1. Fluid Calculations
  1. 1. We use a baby’s birth weight for calculations until they have regained it.
    2. Total Fluids: Obtain total fluids In from I/O flowsheet in Epic. Divide total fluid volume by the reference weight (BW or daily wt) to give mL/kg/day.
      1. Note: Trophic enteral feeds (<20mL/kg/day) are not included in total fluids
    3. Calories: Present total kcal/kg/day in your note and on rounds
      1. HA: [ total volume (ml) x dextrose conc (#/100) x 3.4 kcal/g dextrose ] / wt (kg)
        Lipids: [total volume (ml) x 2 ] / wt (kg)
        Feeds: [total volume (ml) / 30 ml/oz ] x [formula (kcal/oz) / wt (kg) ]
2. Feedings
  1. 1. There are a number of options for feeding babies in the NICU. The following are general guidelines.
    2. Human Milk:
      1. Expressed Mother’s Milk (EMM): In early every case this is the best nutrition, best supports the immature immune system, and is important for preventing necrotizing enterocolitis. Our nurses and lactation specialists are available to help mothers with pumping and breastfeeding when the baby is mature enough. Premature infants usually need fortification added to get enough calcium, phosphorous, protein, and kcals.
        Donor Breast Milk (DBM): We have access to donated, banked human milk via the Northwest Mothers Milk Bank. Women have been screened before donating and the milk is pasteurized. Some immunologic factors are lost during pasteurization but DBM has been shown to decrease risk of NEC compared with formula. DBM may be offered for neonates without available EMM or as a bridge to EMM supply and any of the following scenarios: <34 weeks gestation; babies with gastrointestinal disorders (e.g. gastroschisis, history of NEC); babies with cardiovascular disease, particularly those with risk of compromised systemic circulation (e.g. coarctation of the aorta); other ill infants as determined by the team. Consent must be obtained to order DBM. Consent forms are at the HUC desk.
    3. Fortification: (this is where the Complex Feeding OrderSet will be useful!)
      1. Most premature infants will need additives to their milk to ensure adequate growth (remember goal is 10-15g/kg/day weight gain). There are several options, and we take into account the gestational age and how close a baby is to going home in order to decide.
        Human Milk Fortifier (HMF): Similac HMF (SHMF) is the formulation available at OHSU. This is added to EMM/DBM and can be mixed to 22kcal/oz or 24 kcal/oz. They are not available as an outpatient, so babies need to be changed to a formula fortifier prior to discharge (e.g. Neosure).
        Formula fortification: formula (powder or liquid) can be added to EMM/DBM for additional calories. Neosure is the formula of choice in the NICU for premature infants prior to discharge (in place of HFM), or added in with HMF to make 27 kcal/oz or 30 kcal/oz concentration. Term infants requiring more concentrated feeds can have their milk fortified with term formula (Similac advance) to 22, 24, 27 or 30 kcal/oz.
        Protein Supplementation: VLBW (<1500g ) infants need approximately 4g/kg/day of protein for adequate growth even if the calories are sufficient. (This would take about 180mL/kg/day of feeds with 24 kcal milk, which is too much fluid.) Once fortified, we routinely add a liquid protein supplement to feeds to meet protein needs. This is discontinued when the weight reaches 2 kg.
    4. Formulas:
      1. There are a number of commercial formulas available. Again, breast milk is the preferred source of nutrition.
        Preterm: Similac Special Care (SSC) is preferred as first line formula for premature infants (again can be mixed to several difference concentrations) but is not readily available for outpatients. Neosure is available for outpatient, so we switch to this a couple days before discharge. Babies who are late preterm (and do not have EMM available) can start with Neosure.
        Term: the standard formula is Similac Advance, though Similac Sensitive, hydrolyzed, and elemental formulas are also available.
    5. Feeding Schedules:
      1. Babies are typically set on a q3h feed schedule (PO+NG) until they are taking full feeds PO. Total fluids are typically set to 140-160ml/kg/day. Once they’re taking close to full volume PO feeds, babies can be liberalized to an ad lib feeding with a minimum, calculated out to 12h shifts (shift minimum). Daily minimums are typically 120-140ml/kg/day.
        Trophic feeds (small volume, <20 mL/kg/day) are often started for premature infants to prime their intestine/induce maturation in preparation for higher volume feedings. It is crucial that these are with human milk (preferably mother’s colostrum) in the most immature patients.
        Premature infants tend to have hypomotility and are additionally at risk for necrotizing enterocolitis. We advance their feeds cautiously. Please follow the feeding protocol which can be found on the NICU bridge website (bridge.ohsu.edu).
3. Discharge planning
  1. 1. Update the baby’s discharge summaries regularly. Patient assignments may change day-to-day, so even if you’re not the main provider for the patient, please update the hospital course any time your schedule allows.
      1. The dotphrase is .ipmdpednicudischarge
    2. NICU routine screening exams
      1. ROP exams: BW <1.5kg or GA <31wks, first exam at 4 weeks of life or at 31 weeks CGA, whichever is later
        Carseat test: BW <2.5kg or GA <37wks
        CCHD: pre and post-ductal sats. Not needed if echo completed.
        Newborn Screens: order via admissions ordersets.
        Standard: #1 at 24hrs, #2 at 10-14 days old.
        Triplicate: #1 at admission, #2 at 48hrs, #3 at 28 days. If discharged before 10 days old, obtain at 10-14 days outpatient. If discharged 10-28 days old, obtain at discharge.
    3. NICU education resources
      1. Hospital 2 home class: 2.5hr free class for family members. Goes through infant care, CPR, safe sleep, carseats, etc. Sign up sheets are at front desk.
        March of Dimes resources: Provides activities, emotional support, and outpatient resources for NICU families. Ask the front desk.
        YourNICUbaby.com. Family can login using DNCC account for various parent-centered education materials.
    4. Immunizations
      1. Generally follows standard CDC guidelines, though we don’t give rotavirus vaccines inpatient.
        1^st Hep B dose delayed to 1 month for babies <2kg
        Parent consent needed for vaccines (signature needed on immunization consent form, ask the HUC or the bedside RN)
        Use the dncc immunizations orderset to order vaccines
    5. PCP identification
      1. PCPs will receive weekly updates on their patients.
        All babies must have PCP appointments made and documented (with date and time) for discharge
        Angela Douglas or the fellow will contact the PCPs after discharge to give verbal patient handoff.
    6. Discharge resources
      1. Arnette Kayhani is our case manager. She assists with insurance, outpatient equipment and supplies, helps with selecting PCP, and assists with overall discharge planning.
        Kathleen Bartell (45631) can schedule outpatient ROP exams at casey eye.
        A list of various scheduling pools is posted in the workrooms to use for scheduling outpatient appointments.
        Multi-disciplinary team discusses patients nearing discharge (2 week list) to assist with discharge planning. There are bedside rounds on the 2 week list patients every Tuesday starting at 11am, and there are sit rounds with the multidisciplinary team on Mondays and Fridays at 11:30 in the attending office. Resident participation is optional but welcome.